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INSANITY 

ITS  CLASSIFICATION,  DIAGNOSIS  and  TREATMENT 

A   MANUAL   FOB 

Students  and  Practitioners  of  Medicine 

By  E.  C.  SPITZKA,  M.D. 

PROFESSOR    OF    MEDICAL  JURISPRUDENCE  AND    OF    THE  ANATOMY  AND    PHYSIOLOGY   OP 

THE  NERVOUS  SYSTEM,  AT  THE  NEW  YORK  POST  GRADUATE  SCHOOL   OF  MEDICINE  ; 

PRESIDENT    OF   THE     NEW    YORK     NEUROLOGICAL    SOCIETY  ;      FORMERLY 

PHYSICIAN    TO    THE    DEPARTMENTS     OF    NERVOUS    DISEASES    OF 

THE    METROPOLITAN   THROAT     HOSPITAL,     AND    OF    THE 

NORTH  EASTERN  DISPENSARY 


NEW  YORK 
BERMINGHAM   &   CO. 

1883 


Copyright,  1883,  by  Bermingham  &  Co. 


loo    , 
S76li 


DEDICATED 

TO 

T.    -A..    ]Vi:cBI?,IIDE,    IMI.ID., 

OF  NEW  YORK, 

AS    A    MARK    OF     THE    AUTHOR'S    PERSONAL    ESTEEM,    AND  AN  HUMBLB 

TRIBUTE   TO   HIS  EMINENT   SERVICES  AS  A   TEACHER  AND   ORIGINAL 

INVESTIGATOR  IN  THE  FIELD  OP   CLINICAL  MEDICINE. 


PREFACE. 


The  present  work  was  originally  intended  to  cover  no 
other  ground  than  the  Definition,  Classification,  and 
Diagnosis  of  Insanity.  The  requests  and  suggestions  of  his 
pupils  and  professional  friends  have  induced  the  writer  to 
enlarge  the  original  essay  to  the  dimensions  of  a  general 
treatise.  In  so  doing,  special  stress  has  been  laid  on  those 
points  which  will  probably  prove  comparatively  new  to 
many  American  readers,  and  which  it  might  be  naturally 
expected  would  find  a  place  in  the  first  systematic  treatise 
on  insanity  published  on  this  side  of  the  Atlantic  since  the 
days  of  the  immortal  Rush. 

The  individual  views  of  the  writer  concerning  classifica- 
tion, the  desirability  of  re-establishing  the  group  of  the 
monomanias,  the  pathogenesis  of  paretic  dementia,  the 
mechanism  of  delusions,  and  the  relation  of  somatic  anom- 
alies to  transmitted  insanity  have  been  previously  pub- 
lished in  journal  articles  in  the  Medical  Gazette,  St.  Louis 
Clinical  Record,  the  Chicago  Journal  of  Nervous  and  Mental 
Diseases,  the  American  Journal  of  Neurology  and  Psychiatry, 
and  particularly  in  the  supplement  of  the  latter— the  W.  & 
S.  Tuke  memorial  essay  on  the  "  Somatic  Etiology  of  In- 
sanity." For  fuller  literary  references  than  it  was  deemed 
well  to  introduce  in  a  manual  intended  for  the  general 
practitioner's  use,  the  reader  is  referred  to  the  articles  pub- 
lished in  the  periodicals  mentioned.  A  full  bibliography  will 
accompany  the  larger  work  on  insanity,  which  the  writer 
has  in  preparation  and  which  will  appear  in  a  few  years. 
It  is  scarcely  necessary  for  the  writer  to  state  that  he  has 


lO  PREFACE. 

not  aimed  at  presenting  more  than  a  surface  view  of  the 
domain  of  insanity,  in  a  volume  of  the  modest  dimensions 
of  this  manual.  He  has  felt  that  there  exists  a  need  for  a 
treatise  which,  without  being  so  exhaustive  as  to  tire  and 
bewilder  the  beginner  and  the  general  medical  reader,  shall 
direct  attention  to  such  of  the  salient  points  of  psychiatry 
as  the  general  practitioner  may  be  reasonably  expected  to 
/^  familiarize  himself  with — particularly  if  he  desire^  to  fill 
the  position,  so  often  forced  on  him,  of  acting  as  the  first 
counsellor  of  a  family  in  cases  of  insanity.  The  writer  will 
consider  the  object  of  this  treatise  fully  accomplished  if 
the  task  of  acquiring  the  rudiments  of  a  difficult  and  intri- 
cate branch  of  medicine  is  thereby  rendered  easier.  And 
if  these  lines  should  awaken  an  interest  in  the  subject 
which  will  induce  the  reader  to  consult  those  more  volumi- 
nous and  classical  works  to  which  the  present  one  may  be 
considered  a  mere  introduction,  his  most  sanguine  expecta- 
tions will  be  realized. 

New  York,  137  East  50th  Street, 
April  10,  1883. 


CONTENTS. 


PART   FIRST. 

THE   GENERAL    CHARACTERS  AND    THE    CLASSIFI- 
CATION OF  INSANITY. 


CHAPTER   I. 

FAGB 

The  Definition  of  Insanity 17 

CHAPTER    n. 
The  Delusions  of  the  Insane 23 

CHAPTER    III. 
Imperative  Conceptions  and  Morbid  Propensities 35 

CHAPTER   IV. 
Hallucinations  and  Illusions 43 

CHAPTER   V. 
The  Emotional  Disturbances 54 

CHAPTER   VI. 
The  Memory  and  Consciousness  in  Insanity 57 

CHAPTER    VII.        ^ 
The  Will  in  Insanity 64 

CHAPTER   VIII. 
The  Physical  Indications  of  Acquired  Insanity 65 


12  CONTENTS. 


CHAPTER   IX. 

PAGB 

Somatic  Signs   of  Insanity  Indicating  the  Existence  of  a  Constitu- 
tional Taint  of,  or  a  Predisposition  to  Insanity 8l 

CHAPTER    X. 
The  Morbid  Anatomy  of  Insanity 92 

CHAPTER   XI. 
The  Classification  of  Insanity 113 


PART   SECOND. 

THE    SPECIAL   FORMS   OF  INSANITY. 


CHAPTER    I. 
Mania 131 

CHAPTER    II. 
Melancholia 140 

CHAPTER    III. 
Katatonic  Insanity 149 

CHAPTER    IV. 
Transitory  Frenzy 154 

CHAPTER   V. 
Stuporous  Insanity 158 

CHAPTER   VI. 
Primary  Confusional  Insanity i6i 

CHAPTER    VII. 
o 

Primary  Mental  Deterioration 163 

CHAPTER   VIII. 
The  Secondary  and  Terminal  Deteriorations 166 


CONTENTS.  13 

CHAPTER    IX. 

FAGB 

Senile  Dementia 171 

CHAPTER    X. 
Insanity  of  Pubescence 175 

CHAPTER    XI. 
Paretic  Dementia — Preliminary  Considerations 178 

CHAPTER    XII. 
Paretic  Dementia — Course  and  Symptoms 184 

CHAPTER   XIII. 
Paretic  Dementia — Morbid  Anatomy  and  Theory  of  the  Disease.. .  .   218 

CHAPTER   XIV. 
Syphilitic  Dementia 243 

CHAPTER   XV. 
Delirium  Grave 247 

CHAPTER   XVI. 
Alcoholic  Insanity 251 

CHAPTER  XVII. 
Hysterical  Insanity 256 

CHAPTER   XVIII. 
Epileptic  Insanity 258 

CHAPTER   XIX. 
Periodical  Insanity 267 

CHAPTER  XX. 
The  States  of  Arrested  Development 275 

CHAPTER   XXI. 
Monomania — Preliminary  Considerations 286 

CHAPTER   XXII. 
Monomania — Its  Course  and  Varieties 301 


14  CONTENTS. 

PART   THIRD. 

INSANITY  IN  ITS  PRACTICAL  RELATIONS. 


CHAPTER   I. 

PAGB 

How  to  Examine  the  Insane 320 

CHAPTER   II. 
The  Differential  Diagnosis  of  the  Forms  of  Insanity  330 

CHAPTER   III. 
The  Recognition  of  Simulation 352 

CHAPTER   IV. 
The  Physical  Causes  of  Insanity 369 

CHAPTER   V. 
The  Psychical  Causes  of  Insanity 381 

CHAPTER   VI. 
The  Medicinal  and  Dietetic  Treatment  of  Insanity 384 

CHAPTER   VII. 
The  Psychical  Treatment  and  Management  of  the  Insane 397 


INSANITY, 

Its  Classification,  Diagnosis  and  Treatment. 


PART  I. 


THE    GENERAL     CHARACTERS     AND     THE 
CLASSIFICATION  OF  INSANITY. 


CHAPTER  I. 

The  Definition  of  Insanity. 

Insanity  is  a  term  applied  to  certain  results  of  brain 
disease  and  brain  defect  which  invalidate  mental  integ- 
rity. It  is  inaccurate  to  state  that  insanity  is  itself  a  disease. 
It  is,  strictly  speaking,  merely  a  symptom  which  may  be 
due  to  many  different  morbid  conditions,  having  this  one 
feature  in  common:  that  they  involve  the  organ  of  the 
mind. 

From  this  point  of  view  the  term  insanity  is  used  in  a 
sense  analogous  to  that  in  which  "  aphasia"  is  employed.  The 
aphasic  symptom-group  comprises  derangements  of  the 
function  of  articulate  speech,  which  may  be  manifestations 
of  a  cerebral  defect,  of  gross  cerebral  disease,  and  of  dis- 
turbance in  the  cerebral  circulation.  These  conditions  dif- 
fering so  widely  amongst  themselves  in  their  pathological 
character  must,  in  order  to  produce  aphasia,  agree  in  one 
essential  respect:  their  regional  distribution — that  is,  they 
must  affect  the  central  speech  organ,  the  speech  centres,  and 
the  speech  tracts  in  a  similar  way.  While  the  point  at,  and 
the  extent  to  which  the  cerebral  mechanism  is  disturbed  by 
a  lesion,  determines  the  existence  of  this  prominent  symptom, 
it  is  not  the  location  but  the  intrinsic  nature  of  the  lesion, 


15  INSANITY. 

be  it  a  hemorrhage,  a  tumor,  or  a  nutritive  interference,  that 
determines  the  name  of  the  patient's  disease. 

Theoretically  it  should  be  the  same  with  insanity.  The 
disease  manifesting  mental  derangement  maybe  an  inflam- 
mation of  the  brain  and  its  membranes,  or  a  brain  injury — 
a  brain  wasting,  or  an  original  brain-defect — a  mal-nutrition, 
or  a  reflex  disturbance  of  that  organ;  and  in  such  conditions 
must  we  seek  for  the  groundwork  of  a  scientific  nomencla- 
ture and  classification  of  the  morbid  states  underlying 
mental  derangement.  Unfortunately,  sufficient  positive  ob- 
servations on  which  to  base  a  thorough  pathology  of  these 
diseased  states  are,  as  yet,  desiderata.  The  scalpel,  the  test- 
tube,  the  microscope,  the  sphygmograph,  the  ophthalmo- 
scope, and  delicate  electrical  apparatus  have  been  diligently 
employed  by  able  and  earnest  investigators;  but  these  ap- 
pliances and  the  most  elaborate  methods  of  the  laboratory 
have  more  frequently  failed  than  succeeded  in  revealing  the 
organic  conditions  responsible  for  mental  disturbance. 

It  is  for  this  reason  that  while  the  ideal  aim  of  the  pro- 
gressive alienist  will  continue  to  be  the  solution  of  the 
great  problem  of  the  physical  foundation  of  insanity,  he 
is  commonly  limited  when  he  makes  a  diagnosis  to  a  recog- 
nition of  disease  manifestations,  and  not  of  disease;  when 
he  classifies,  to  a  classification  of  symptom  groups;  and 
when  he  treats  insanity,  to  the  treatment  of  symptomatic 
states.  The  conceptions  and  processes  of  mental  science  are 
hence  traditional  and  empirical  to  a  great  extent.  In  some 
degree  this  is  also  due  to  the  fact  that  the  conventional 
discrimination  between  insanity  and  other  symptoms  of 
disease  of  the  brain,  however  practically  necessary,  is  from  a 
scientific  point  of  view  both  arbitrary  and  artificial.  This 
becomes  most  evident  when  we  attempt  to  define  insanity. 

It  may  be  safely  asserted  that,  in  the  present  state  of  our 
knowledge,  it  is  impossible  to  frame  a  definition  of  insanity 
which,  while  it  meets  the  practical  every-day  requirements, 
is  constructed  on  j-«V;////?^  principles.  The  failure  of  the  best 
authorities  to  furnish  such  a  one  proves  that  until  the  ma- 
terial elements  of  mental  derangement  become  more  acces- 
sible to  observation  than  they  now  are,  scientific  definitions 
must  in  large  part  rest  on  hypotheses.  Tht  practical  need, 
however,  is  for  a  definition  which  shall  include  neither  am- 
biguous nor  theoretical  terms.  That  the  brain  is  the  organ 
of  the  mind  is  an  axiom  of  physiology,  that  insanity  is  a  man- 
ifestation of  a  brain  disorder  is  a  resulting  dogma  of  medical 


THE   DEFINITION   OF   INSANITY.  I9 

psychology;  but  even  if  we  could  establish  the  existence  of 
a  brain-lesion  in  every  case  of  brain  disturbance,  we  would 
not  be  able  to  formulate  the  topographical  and  patho-his- 
tological  conditions  which  determine  the  falling  of  its  mani- 
festations within  the  boundaries  of  insanity  in  one  case,  and 
without  them  in  another.  And  neither  the  axioms  of  phy- 
siology nor  the  dogmas  of  medical  psychology  are  regarded 
with  sufficient  respect  in  our  courts  of  law — where  the  prob- 
lem of  an  accurate  definition  of  insanity  is  apt  to  be  most 
emphatically  presented  to  the  medical  mind — to  render  their 
use  in  filling  this  gap  in  our  knowledge  either  satisfactory 
or  profitable.* 

The  following  appears  to  the  writer  to  comply  with  the 
chief  requirements  of  a  practical  definition,  although  it  la- 
bors under  the  disadvantage  of  length: 

Insatnty  is  either  the  inability  of  the  individual  to  correctly  reg- 
ister and  reprodjice  impressions  {and  conceptions  based  oti  these)  in 
sufficient  number  and  intensity  to  serve  as  guides  to  actions  in  har- 
mony tvith  the  individual's  age,  circtnnstances,  and  surroundings, 
and  to  limit  himself  to  the  registration  as  subjective  realities  of 
impressions  transmitted  by  the  peripheral  organs  of  sensation;  or 
the  failure  to  properly  co-ordinate  such  impressions,  and  to  thereon 
frame  logical  conclusions  and  actions :  these  inabilities  and  fail- 
ures being  in  every  instance  considered  as  excluding  the  ordinary 
influence  of  sleep,  trance,  somnambulism,  the  common  manifesta- 
tions of  the  general  neuroses,  such  as  epilepsy,  hysteria  and  chorea, 
of  febrile  delirium,  coma,  acute  intoxications,  intense  mental  pre- 
occupation, and  the  ordinary  immediate  effects  of  nervous  shock 
atid  injuty. 

The  first  condition  of  a  definition  is  that  it  shall  be  de- 
scriptive of  the  subject  to  be  defined.  The  above  depicts 
the  fundamental  error  at  the  root   of  every  form  of  those 

*  It  is  significant  in  this  connection,  that  none  of  the  most  recent  Ger- 
man writers  on  insanity  attempt  to  give  a  definition  of  "  insanity."  The 
chief  discussion  as  to  the  possibility  of  concocting  such  a  definition  has 
taken  place  in  the  Anglo-Saxon  countries,  and  this  for  reasons  it  is  not 
necessary  to  dilate  on,  indicates  that  the  chief  need  for  the  definition  is 
a  medico-legal  one.  If  this  want,  were  not  the  main  motor,  it  is  doubtful 
whether  an  English  author  on  Lunacy  (Shepard)  would  have  offered  such 
a  definition  as  "  insanity  is  a  disease  of  the  neurine  batteries  of  the  brain," 
with  such  an  object  as  his  avowed  one  of  puzzling  the  lawyers!  That  a 
clearly  formulated  definition  of  insanity  is  not  indispensable  to  the  sci- 
entific psychiatrist  is  illustrated  by  the  incontestable  fact  that  mental 
pathology  has  made  more  rapid  progress  in  Germanv,  Italy  and  France, 
where  little  stress  is  laid  on  such  definitions,  than  in  England  or  America. 


20  INSANITY. 

acquired  and  congenital  mental  deficiencies  and  perversions 
which  pass  under  the  designation  insanity.  The  "inability 
to  correctly  register  experiences  and  impressions  in  suffi- 
cient number"  to  serve  as  guides  to  rational  conduct  is  the 
essential  feature  of  idiocy  and  imbecility,  whether  moral  or 
intellectual.  The  inability  to  limit  the  registration  of  im- 
pressions to  such  as  are  "received  by  the  peripheral  organs 
of  sensation,"  is  the  foundation  of  the  insane  hallucina- 
tion and  illusion.  The  failure  to  co-ordinate  impressions 
as  the  basis  of  "  logical  conclusions,"  is  the  characteristic 
feature  of  those  insanities  manifesting  themselves  by  the 
formation  of  delusive  opinion,  insane  projects,  and  impera- 
tive conceptions.  Finally,  the  impaired  reproduction  of 
those  impressions  and  experiences  which  are  to  serve  as 
guides  to  rational  conduct,  constitutes  the  main  feature  of 
those  acute  insanities  and  their  secondary  sequelae  which 
are  not  covered  by  the  other  terms  of  the  definition.  The 
latter,  therefore,  complies  also  with  the  second  condition 
of  a  definition,  in  that  it  covers  the  whole  ground  included 
under  the  term  which  it  is  intended  to  define. 

The  qualifying  clauses  are  added  for  the  purpose  of  filling 
the  third  requirement:  that  nothing  outside  the  limits  of 
the  field  to  be  defined  shall  be  included  in  the  definition. 
The  words  "in  harmony  with  the  individual's  age,  circum- 
stances, and  surroundings,"  exclude  the  elements  of  imma- 
turity, mal-development  of  the  sense-organs  and  members, 
defective  education,  and  the  influence  of  great  popular 
movements  on  the  human  mind.  They  predicate  as  the 
standard  of  mental  health  that  of  the  age  which  the  indi- 
vidual has  reached,  of  the  period  of  time  in  which  he  lives, 
and  of  the  class  of  society  to  which  he  belongs.  In  other 
words,  the  definition  accommodates  itself  to  the  fact  that 
the  standard  of  mental  health  is  a  variable  one.  A  lack  of 
understanding,  of  reasoning  power  and  of  responsiveness, 
which  would  be  a  grave  indication  of  unsoundness  of  mind 
in  a  person  of  previously  high  intellectual  power  and  cul- 
ture, might  not  have  so  grave  a  meaning  in  the  case  of  a 
member  of  the  lower  orders  of  society  or  of  an  inferior  race. 
The  normal  intellectual  status  of  a  Tasmanian  is  quan- 
titatively inferior  to  that  of  some  Caucasian  imbeciles;  and 
indeed  authors  have  compared  certain  manifestations  of 
insanity  to  anthropological  degenerations  in  an  atavistic 
sense.  Again,  the  conduct  of  a  Hindoo  fakir,  of  a  reli- 
gious fanatic,  or  a  revivalist,  while  it  oversteps  the   boun- 


THE   DEFINITION   OF   INSANITY.  21 

daries  of  reason  in  more  than  one  direction,  is  not  insanity; 
because,  however  strange  and  suggestive  of  insanity  such 
conduct  may  be,  it  is  in  consonance  with  the  individual's 
surroundings,  and  the  result  of  educational  influences  and 
mental  contagion  occurring  within  physiological  limits. 

Similar  qualifications  apply  to  the  more  positive  signs  of 
insanity.  Beliefs  which  in  the  earlier  periods  of  history 
were  creeds  with  the  majority  of  mankind  would  to-day  in 
members  of  a  civilized  race  rank  with  the  insane  delusion. 
The  behavior  of  the  adolescent,  if  marking  the  conduct  of 
a  person  of  mature  years,  has  a  sinister  signification  which 
it  does  not  have  at  the  period  of  life  to  which  such  conduct 
naturally  appertains.  The  phantastic  tendencies  of  the 
child,  the  prodigality  and  romancing  of  youth,  the  conser- 
vatism, lethargy,  and  miserly  inclinations  of  old  age,  are 
phases  in  the  normal  evolution  and  involution  of  mind;  but 
phantastic  tendencies  in  a  person  of  middle  life,  prodigality 
and  romancing  in  aged  persons,  or  habitual  suspiciousness, 
miserliness,  and  lethargy  in  a  child  or  youth,  constitute  wide 
departures  from  the  standard  of  mental  health  of  those  re- 
spective periods  of  life,  and  suggest,  if  they  do  not  prove, 
the  existence  of  insanity. 

In  characterizing  the  insane  hallucination  and  illusion, 
that  is,  the  registration  of  impressions  which  either  are  not 
received  at  all  or  imperfectly  transmitted  from  the  peripheral 
organs  of  sensation,  it  is  necessary  to  add  the  words  "sub- 
jectively real,  "  because  hallucinations  not  accepted  as  reali- 
ties sometimes  occur  in  the  sane  (as  when  Goethe  met  his 
own  figure  on  the  road  from  Strasburg  to  Sesenheim),  and 
herein  differ  from  the  insane  hallucination,  whose  reality 
the  patient  is  convinced  of  for  the  time  being.  It  is  also 
necessary  to  specify  that  a  registration  does  not  enter  the 
field  of  mental  unsoundness  unless  it  is  unjustified  by  a 
peripheral  impression.  We  thus  exclude  from  the  domain 
of  insanity  the  deceptive  impressions  produced  by  diplopia, 
scotomata,  photopsia,  diseases  of  the  peripheral  nerves,  and 
the  entotic  sounds  as  well  as  those  arising  from  imperfec- 
tions of  the  sense  organs. 

Here  the  definition  might  terminate  from  a  strictly  scien- 
tific point  of  view;  it  is  thus  far  merely  a  paraphrase  of  the 
dictum  that  insanity  is  a  deficiency  or  perversion  of  the 
mental  faculties,  not  provoked  by  any  external  cause,  but 
arising  and  developing  within  the  ego.  There  are,  however, 
many  conditions  of  temporary  deficiency  or  perversion  of 


22  INSANITY. 

the  mind,  not  provoked  by  any  external  cause,  which  do 
not  fall  within  the  strict  conception  of  insanity,  and  must 
be  excluded  in  its  definition.  The  phenomena  of  halluci- 
natory insanity  and  stupor  are  closely  simulated  by  febrile 
delirium  and  coma;  Indian  hemp  produces  a  condition  very 
much  like  a  mild  form  of  expansive  mania;  finally,  alcoholic 
intoxication  imitates  in  its  various  degrees  almost  every 
phase  of  paretic  dementia. 

In  excluding  the  phenomena  of  intoxication  it  is  necessary 
to  employ  the  qualifying  adjective  "  acute,"  because  the 
chronic  intoxications  producing  those  results  detailed  in  the 
definition,  are  actual  insanities;  alcoholic  and  opium  insan- 
ity being  examples. 

The  bearing  of  the  remaining  qualifying  clauses  is  almost 
self-evident.  Several  of  them  would  be  unnecessary  but 
for  the  desirability  of  meeting  even  the  most  finical  and 
hypercritical  objections  in  a  definition  whose  chief  uses  are 
of  a  medico-legal  nature.  The  ordinary  phenomena  of  epi- 
lepsy, hysteria,  and  the  immediate  results  of  nervous  injury 
and  shock  are  not  insanity;  but  the  extraordinary  cov[\'^X\cdi- 
tions  of  the  ordinary  nervous  diseases  and  the  remote  con- 
sequences of  nervous  shock  and  injury,  if  these  lead  to  the 
development  of  the  signs  included  in  the  first  clauses  of  the 
definition,  respectively  become  insanity  of  the  epileptic, 
hysterical,  choreic,  and  traumatic  variety. 

Mental  concentration  and  preoccupation  lead  to  some  of 
the  results  which  might  be  included  under  the  clause,  "in- 
ability to  correctly  register  and  reproduce  impressions  in 
sufficient  number  and  intensity  to  serve  as  guides  to  action 
in  consonance  with  the  individual's  age  and  surroundings." 
The  abstracted  man  stuffing  his  pipe  with  his  neighbor's 
finger,  the  Scotch  professor,  who,  reminded  that  he  had 
omitted  to  apologize  to  a  lady  against  whom  he  had  stum- 
bled, politely  excused  himself  to  the  cow  who  next  collided 
with  him,  Archimedes  oblivious  that  the  soldier  rushing  into 
his  apartment,  where  he  was  engaged  over  a  geometrical 
problem,  was  about  to  kill  him,  the  soldier  who,  in  the  ex- 
altation of  battle,  rushes  on  after  receiving  a  fatal  wound, — 
are  all  instances  of  the  action  of  physiological  laws,  whose 
results  have  a  superficial,  but  only  a  very  superficial,  resem- 
blance to  the  abstraction  of  certain  demented  patients,  and 
which  require  to  be  excluded  by  the  physician  when  defin- 
ing insanity  to  those  who  are,  or  affect  to  be,  misled  by  sur- 
face resemblances. 


THE   DELUSIONS   OF   THE   INSANE.  23 

On  some  occasion  the  question  of  defining  what  is  called 
"legal  insanity"  may  be  presented  to  the  reader  of  these 
lines.  When  that  question  is  asked,  he  may  safely  challenge 
the  questioner  to  show  him  a  broken  leg  or  a  case  of  small- 
pox in  a  hospital  ward  which  is  not  a  broken  leg  or  a  case  of 
small-pox  in  law;  to  show  him  a  tumor  or  a  softening  of 
the  brain,  which  is  meningitis  or  sclerosis  in  law,  or  to  de- 
fine the  conditions  under  which  any  disease-symptom  be- 
comes an  indication  of  health.  When  these  conditions 
are  complied  with,  and  not  till  then,  may  the  physician  at- 
tempt to  define  "  insanity  in  law"  as  distinguished  from  in- 
sanity in  science.  In  the  mean  time  he  may  rest  contented 
with  the  dictum  of  one  of  the  best  legal  authorities  that 
that  cannot  be  sanity  in  law  which  is  insanit}^  in  science, 
just  as  nothing  can  be  a  fact  in  science  and  a  fiction  in  law  at 
one  and  the  same  time. 


CHAPTER  II. 

The  Delusions   of  the  Insane. 

The  characteristic  evidences  of  insanity,  although  they  are 
all  manifestations  of  disordered  action  of  the  central  ner- 
vous axis,  may  for  practical  purposes  be  divided  into  two 
groups:  the  mental  symptoms  proper,  and  the  somatic,  or 
the  physical  indications.  While  the  former  are  mainly- ob- 
jects of  study  for  general  diagnostic  and  medico-legal  pur- 
poses, and  furnish  important  hints  for  moral  treatment,  the 
latter  constitute  our  guides  for  physical  treatment,  and  en- 
lighten us,  as  far  as  signs  observed  during  life  can,  as  to  the 
fundamental  nature  of  the  disorder.  The  significance  of 
these  physical  evidences,  however  profound  it  appears  to 
the  experienced  mental  pathologist,  is  appreciable  and  in- 
teresting to  the  student  only  when  taken  in  connection 
with  what  even  the  untutored  eye  regards  as  the  essential 
and  characteristic  feature  of  insanity:  its  mental  results. 
It  is  therefore  best  to  begin  the  consideration  of  the  subject 
with  the  latter. 

To  probably  no  other  class  of  symptoms  of  mental  de- 
rangement does  so  much  interest  and  interest  of  so  mani- 
fold a  character  attach  as  to  the  delusions  of  the  insane. 
These  perversions  of  the  conceptional  sphere  have  indeed 


24  INSANITY. 

had  the  high  medico-legal  position  assigned  to  them — it  is 
scarcely  necessary  to  add,  erroneously — of  constituting  the 
criteria  of  insanity,  and  from  the  days  of  Willis,  Haslam,  and 
Esquirol  down,  practical  alienists  have  based  many  impor- 
tant indications  for  prognosis  and  treatment  of  mental  dis- 
orders, on  the  special  character  of  the  delusions  accompany- 
ing them. 

There  is  no  evidence  of  insanity  which  constitutes  so 
proper  a  starting-point  for  study  as  the  insane  delusion. 
Though  even  on  first  sight  the  most  complex  and  mysteri- 
ous of  the  symptoms  of  mental  disorder,  it  is  yet  that  man- 
ifestation which  strikes  the  mind  of  the  novice  with  the 
greatest  force.  It  is  the  symptom  to  which  the  readiest  ex- 
pression is  given  by  the  patient  himself;  the  one  which  can 
be  most  readily  laid  bare  before  a  class  in  the  course  of 
clinical  demonstration;  and  the  one  which  offers  to  the  be- 
ginner in  psychiatry  that  obvious  contrast  with  sanity  which 
is  the  most  satisfactory  because  the  most  tangible  to  his 
mind.  For  the  very  reason  that  the  insane  delusion  is  con- 
sidered to  be  the  criterion  of  insanity  by  the  laity  and  the 
legal  profession,  the  common  presence  and  patency  of  this 
symptom  in  the  insane,  it  should  constitute  the  introduc- 
tion to  the  study  of  the  subject. 

The  lay  conception  of  a  lung  disorder  associates  it  with 
cough  and  expectoration.  Now,  while  cough  and  expecto- 
ration do  not  constitute  the  most  essential  signs  of  lung 
affections,  yet  the  clinical  teacher  who  will  analyze  these 
phenomena  before  the  new-comer,  and  point  out  their  true 
meaning  before  proceeding  to  the  physical  signs — whose 
recognition  and  interpretation  require  experience  and  acu- 
men— does  that  new-comer  a  far  greater  service  than  he  who 
endeavors  to  override  the  untutored  mind  by  ignoring  all 
which  the  latter  has  hitherto  been  cognizant  of,  and  by 
presenting  abstractions  which  the  beginner  is  altogether 
unfitted  to  comprehend. 

Insane  delusions,  that  \s,  faulty  ideas  growing  out  of  a  per- 
version  or  jveakening  of  the  logical  apparatus,  are  primarily 
divided  by  authorities  according  to  their  expansive  or  de- 
pressive character;  and  further  subdivisions  are  based  on 
the  contents  of  the  delusion,  as  to  whether  it  relates  for  ex- 
ample to  sexual,  political,  religious,  or  bodily  matters. 
Thus  expansive  delusions  include:  ambitious,  erotic,  and  re- 
ligious ones;  the  depressive  group:  hypochondriacal  delu- 
sions and  those  of  persecution. 


THE   DELUSIONS   OF   THE   INSANE.  2$ 

All  these  terms  are  admissable  designations  of  what  are 
frequently  accidental  characters  of  the  delusion;  but  any 
system  of  classification  which  bases  fundamental  distinc- 
tions on  them,  is  necessarily  faulty  (see  Monomania).  A 
paretic  dement  may  entertain  the  delusion  that  he  is  a 
king-,  so  may  a  monomaniac  and  so  may  an  imbecile  or  a 
dement;  but  nowhere  does  an  old  German  saying,  which 
translated  reads:  when  two  do  the  same  thing  it  is  not  there- 
fore the  same — apply  so  well  as  here.  In  the  cases  hinted 
at,  although  the  external  dress  of  the  delusion  is  formally 
the  same,  yet  its  logical  foundation  and  structure  is  different 
in  each.  To  study  that  difference  is  to  analyze  the  essential 
nature  of  the  insanity  of  which  the  delusion  is  but  an  evi- 
dence. As  a  result  of  such  a  study  it  is  found  that  the  ex- 
ternal dress  of  the  delusion  is  of  very  subsidiary  importance. 
Its  essential  features  are  the  method  in  which  it  has  been 
developed  and  the  manner  in  which  it  is  defended  by  the 
patient. 

Delusions  may  be  divided  into  the  genuine  and  \\\&  spji- 
rioiis.  The  former  group  consists  of  those  delusions  which 
have  been  mainly  created  by  the  patient  himself;  the  latter, 
of  those  which  have  been  altogether  adopted  from  others. 
The  former  alone  are  of  intrinsic  importance  to  the  alienist; 
the  latter  have  only  a  relative  bearing  to  such  extent  as  it 
may  be  necessar}''  to  consider  the  possibility  of  their  exist- 
ence as  a  factor  in  differential  diagnosis.  They  are  found 
in  weak-minded  patients  as  evidences  of  an  imitative  ten- 
dency. 

The  genuine  delusions  of  the  insane,  when  classified 
according  to  their  synthesis,  naturally  fall  into  two  great 
groups.  We  find  that  certain  delusions  have  a  complex  log- 
ical organization — the  systematized  delusions;  while  oth- 
ers are  devoid  of  such  an  organization,  are  not  as  plausibly 
based,  as  elaborately  expressed,  and  as   skilfully  defended 

THE  unsystematized  DELUSIONS. 

The  various  forms  of  delusion  ordinarih''  admitted  fall 
under  both  of  these  heads.  That  is,  we  may  have  either 
delusions  of  grandeur  or  depressive  delusions  of  the  S)'S- 
tematized  as  well  as  of  the  unsystematized  type,  and  the 
same  applies  to  their  sub-varieties.  In  order  to  fully  char- 
acterize a  given  delusion,  it  hence  becomes  necessary  to  in- 
corporate all  these  elements.  If,  for  example,  a  medical  stu- 
dent, as  in  a  reported  case,  believes  that  he  is  suffering  from 
spinal  disease,  and  bases  this  delusion  on  alleged  symptoms 


26  INSANITY. 

which  might  justify  the  belief,  if  they  were  not  due  to  illu- 
sional  misinterpretations  and  hallucinatory  visions  of  his 
spinal  cord,  he  is  suffering  from  a  systematized  hypocho/idrl- 
acal  delusion.  But  a  person  who  is  unable  to  give  connected 
reasons  for  such  beliefs  as  that  his  body  is  decaying,  that 
his  heart  is  turned  to  ice,  and  that  his  intestines  are 
stopped  up,  is  afflicted  with  an  unsystematized  hypochondriacal 
delusion.  In  like  manner  the  patient  who  claims  that  he  is 
pursued  by  enemies,  because  he  imagines  that  people  are 
•)/  looking  at  him  in  a  peculiar  way,  dogging  his  footsteps^ 
putting  poison  in  his  food,  calling  out  his  name  at  night; 
and  that  they  do  all  this  to  prevent  him  from  making  good 
his  claims  to  a  throne,  an  authorship,  or  an  invention,  is  a 
sufferer  from  systematized  delusions  of  persecution.  While  he 
who  alleges  that  he  is  pursued  by  voices  and  by  persons, 
■although  he  does  this  on  the  strength  of  similar  hallucina- 
tions, and  can  assign  no  other  ground  than  a  subjective 
feeling  of  worthlessness  or  criminality,  exhibits  the  unsys- 
tematized delusion  of  persecution. 

To  answer  the  question  as  to  whether  a  given  delusion 
is  systematized  or  unsystematized,  is  of  vastly  greater  im- 
portance than  to  determine  its  more  superficial  features. 
Take  a  persecutory  delusion,  for  example!  If  it  is  systema- 
tized, it  may  be  assumed  that  we  have  to  deal  with  that 
chronic  primary  insanity,  the  Verruecktheit  of  the  Germans, 
the  Monomanie  of  the  French,  the  Monomania  of  some  Eng- 
lish authors.  If,  on  the  other  hand,  it  is  unsystematized, 
we  know  with  equal  certainty  that  the  patient's  disorder  is 
a  melancholia,  unless  other  evidences  point  to  the  existence 
of  senile  and  secondary  insanity,  or  of  paretic  dementia  in 
its  first  stage.     (See  Diagnosis.) 

When  we  proceed,  a  little  later  on,  to  analyze  the  mech- 
anism of  the  principal  varieties  of  systematized  expan- 
sive delusions,  namely,  the  simple.,  or  those  relating  to  so- 
cial and  political  ambitions;  the  erotic,  or  those  involving 
sexual  relations,  and  the  religious.,  we  will  find,  that  while 
they  all  indicate  a  certain  degree  of  logical  enfeeblement, 
that  this  enfeeblement  is  more  pronounced  in  the  case  of 
the  two  latter  varieties  than  of  the  former.  The  highest 
general  mental  activity  is  found  with  those  lunatics  who 
cherish  systematized  delusions  of  social  ambition;  the  pa- 
tients who  are  the  political  reformers,  claimants  to  thrones, 
inventors  of  flying  machines,  or  the  perpetuum  7nobile,  and 
panaceas  for  all  earthly  ills,  the  poets,  the  military  and  the 


THE   DELUSIONS   OF   THE   INSANE.  2^ 

diplomatic  geniuses  of  asylums.  The  patient  here  acts  con- 
sistently with  his  assumed  character,  and  the  continued  ex- 
istence of  a  certain  amount  of  mental  ability  and  energy  is 
shown  by  the  formation  of  projects  which,  whatever  their 
ultimate  feasibility — and  they  sometimes  are  feasible — 
are  undertaken  with  some  attention  to  the  patient's  actual 
circumstances  and  to  detail.  Sometimes,  especially  with 
patients  of  high  previous  culture,  the  systematized  expan- 
sive delusion  is  not  of  such  a  character  as  to  lead  to  an 
error  in  the  patient's  sense  of  identity,  but  limited  to  his 
self-esteem  in  the  abstract.  He  writes  doggerel  or  mediocre 
verse,  for  example,  and  imagines  himself  as  great  a  poet  as 
Byron;  or  he  invents  some  unimportant  mechanical  con- 
trivance, and  lays  claim  to  the  gratitude  of  a  nation  or  a 
king.  Not  infrequently  he  commits  plagiarism  in  a  quasi- 
unconscious  manner. 

Systematized  delusions  of  an  erotic  character  are  found  as  the 
leading  symptoms  of  the  so-called  "Erotomania."  This 
perversion  is  not  necessarily  accompanied  by  animal  sexual 
desire,  and  the  adjective  erotic  is  here  used  in  its  classical 
sense.*  The  patient,  noted  in  his  adolescence  for  his  ro- 
mantic tendencies,  construes  an  ideal  of  the  other  sex  in  his 
day-dreams,  and  subsequently  discovers  the  incorporation  of 
this  ideal  in  some  actual  or  imaginary  personage,  usually  in  a 
more  exalted  social  circle  than  his  own.  He  then  spins  out 
a  perfect  romance  with  the  adored  personage  as  its  subject, 
and  according  as  the  external  circumstances  appear  to  him 
momentarily  favorable  or  unfavorable,  expansive  or  depres- 
sive delusions  are  added  to  and  incorporated  with  the  ero- 
tic ones.  As  a  rule  the  affection  for  the  adored  object 
remains  as  chaste  and  pure  as  it  begins;  a  sort  of  distant, 
romantic  worship,  insane  for  the  reason  that  unimportant 
occurrences,  accidental  resemblances,  facts  which  have  no 
natural  connection  with  the  individual  or  his  or  her  real  or 
imaginary  contemplated  partner,  and  hallucinations  are 
woven  into  the  delusive  conception,  which  consequently  as- 
sumes such  a  predominating  position  in  the  patient's  men- 
tal horizon  as  to  entirely  overshadow  it. 

Systematized  delusiofis  of  a  religious  character  are  usually 
rooted   in  an  early    developing    devotional    tendency,  and 

*  In  the  treatise  of  Bucknill  and  Tuke  erotomania,  and  the  so-called 
"  nymphomania,"  which  is  an  entirely  different  condition  and  not  neces- 
sarily accompanied  by  delusions,  nor  ordinarily  by  amatory  conceptions 
of  the  higher  kind,  are  thrown  together. 


28  INSANITY. 

•brought  to  full  bloom  by  incidental  circumstances,  either 
actual  or  in  the  shape  of  hallucinations.  It  is  not  uncom- 
mon to  find  such  patients  designated  as  cases  of  religious 
melancholia,  because,  supposing  themselves  assailed  by  in- 
imical or'diabolical  forces,  or  commanded  to  fast  for  a  long 
period,  or  forever,  the}"  become  sad  and  anxious  or  refuse 
food.  But  to  call  a  patient  who,  aside  from  these  actions, 
which  are  consistently  regulated  by  the  false  ideas,  be- 
lieves himself  or  herself  to  be  God,  the  Christ,  a  saint,  the 
Messiah,  a  religious  reformer,  or  the  Virgin  Mary,  and  who, 
perhaps,  the  very  next  day  passes  into  visionary  or  ecstatic 
states,  all  the  time  systematizing  his  or  her  acts  and  notions 
— a  melancholiac,  is  to  involve  one's  self  in  a  profound  con- 
tradiction with  the  established  use  of  that  term. 

Among  the  systematized  delusions  of  a  depressive  char- 
acter, the  antitheses  of  all  the  preceding  forms  are  found. 
This  is  well  exemplified  in  cases  where  the  subjects  devel- 
op delusions  of  persecution  overwhelming  the  ambitious 
notions  previously  dominating  the  mental  sphere.  How 
very  unessential  the  line  of  demarkation  between  the  de- 
pressive and  expansive  delusion  really  is,  is  made  apparent 
by  the  fact  that  an  expansive  religious,  erotic,  or  socially 
ambitious  delusion  may  within  a  few  days  become  depres- 
sive through  the  development  of  persecutory  ideas;  just  as 
the  reverse  is  occasionally  observed.  In  fact,  such  expan- 
sive and  depressive  delusions  often  are  entertained  by  the 
patient  at  one  and  the  same  time. 

When  an  individual,  w-ithout  any  manifest  disturbance  of 
his  emotional  or  affective  state,  in  full  possession  of  the 
memories  accumulated  in  the  receptive  sphere,  and  able  to 
carry  out  most  or  all  of  the  duties  of  his  particular  position 
in  life,  as  some  of  the  sufferers  are,  is  found  to  cherish  such 
a  gross  error  as  an  insane  delusion,  firmly  believing  in  the 
reality  of  that  which  from  his  education  and  surroundings 
he  would  be  expected  to  recognize  as  absurd,  the  observer 
is  naturally  puzzled  to  account  for  the  phenomenon.  The 
component  elements  of  the  systematized  delusion  are  in- 
dividually the  same  as  those  which  are  combined  to  form 
healthy  conceptions;  they  differ  in  that  they  are  faultily 
united.  In  this  respect  the  insane  delusion  does  not  differ 
from  the  faulty  conclusions  which  constitute  the  error  of 
the  sane.  But  while  the  error  of  the  sane  person  is  based 
on  faulty  and  not  on  perverted  perceptions,  on  imperfect  or 
vicious  training,  and  on  lack  of  experience,  and  disappears 


THE   DELUSIONS    OF   THE   INSANE.  29 

before  the  corrected  evidence  of  the  senses,  improved  edu- 
cational methods,  and  broader  experience;  the  sufferer  from 
the  insane  delusion  is  unable,  for  the  time  being,  to  correct 
that  delusion  by  a  similar  process.  His  logical  apparatus 
stands  powerless  before  the  controlling  conception.  There 
is  a  fundamental  weakening  of  those  logical  inhibitions  or 
checks  which  the  collateral  elements  of  the  ego  constitute 
for  the  day-dreams  and  speculations  of  a  sane  person. 
What  is  a  wish  or  fear  of  the  sane  mind  becomes  an  article 
of  faith  with  the  delusional  lunatic;  what  is  a  mere  possi- 
bility in  reality  becomes  a  fixed  fact  in  support  of  that 
article  of  faith  with  the  insane;  and  finally  the  perceptions 
themselves  are  perverted  and  enslaved  to  add  new  building 
material  to  the  faulty  mental  structure.  It  is  because  the 
physiological  ego  is  weakened  that  the  morbid  ego  is  per- 
mitted to  arise  out  of  the  small  beginnings  which  a  healthy 
ego  could  have  held  in  check,  and  for  this  reason  the  follow- 
ing legal  definition  of  the  insane  delusion — that  it  is  a  faulty 
belief,  out  of  which  the  subject  cannot  be  reasoned  by  adequate 
methods  for  the  time  being — is  a  sound  one.* 

Notwithstanding  the  fact  that  the  delusions  of  the  sys- 
tematized variety  are  correlated  with  the  patient's  surround- 
ings, in  contradistinction  to  the  unsystematized  delusions, 
which  are  not  correlated  at  all,  they  are  faultily  associated. 
While  there  is  a  chain  of  reasoning  connecting  the  items  of 
the  systematized  delusion  into  an  organized  whole,  which  is 
absent  in  the  uns3^stematized  delusion,  yet  after  all  that 
reasoning  is  onXj  pseudo-logical.  The  systematized  delusion 
is  more  similar  to  a  sane  conception  than  the  unsystematized 
delusion;  yet  this  similarity  does  not  pass  beyond  the  de- 
gree of  an  analogy. 

As  illustrating  the  readiness  with  which  systematic  de- 
lusionists  utilize  casual  occurrences  in  the  construction 
and  defence  of  their  delusions,  it  is  but  necessary  to  refer 
to  the  common  case  where  such  subjects  detect  a  connec- 
tion between  their  delusive  hopes  or  fears  and  an  advertise- 
ment or  a  bill-poster  containing  their  initials;  that  others 
sustain  the  allegation  of  a  royal  descent  by  a  fancied  re- 
semblance to  some  member  of  a  reigning  family;  and  that 
still  others  lay  claim  to  an  important  office  on  the  strength 

*  This  definition  is  somewhat  modified  from  that  given  by  Ray  and 
others,  which  fails  to  provide  for  the  possibility  of  the  lunatic's  correcting 
some  of  his  delusions  during  his  insanity,  and  of  correcting  all  of  them 
if  he  convalesces. 


30  INSANITY. 

of  a  friendly  interview  with  some  little  great  man  of  the 
day.  The  case  of  a  lady  whom  the  writer  treated  several 
years  ago  illustrates  this  readiness  with  which  trifling  mat- 
ters are  framed  into  delusions,  very  aptly.  From  the  facts 
that  the  irides  of  her  child  changed  color  (which  was  an 
occurrence  corroborated  by  the  grandmother  and  others), 
and  that  it  had  greatly  altered  in  appearance  owing  to  an 
exhausting  illness,  she  concluded  that  it  was  not  her  own 
child.  Her  nursery  maid  and  one  of  a  neighboring  fam- 
ily had  been  together  a  great  deal,  and  she  claimed,  what 
was  in  itself  not  impossible,  that  her  child  had  been  ex- 
changed. Although  the  observant  relatives  were  able  to 
prove  the  identity  of  the  child  by  a  number  of  circumstances 
which  would  have  been  held  satisfactory  in  any  court  of  law, 
and  which  would  have  convinced  any  sane  person,  she  only 
interpreted  the  remonstrances  made  as  attempts  to  make 
the  best  of  the  case;  and  because  her  husband  affected  to 
treat  her  suspicions  with  indifference  she  reasoned  that  he 
was  becoming  neglectful  of  his  family.  A  few  ordinary 
civilities  exchanged  by  him  with  several  ladies  belonging 
to  the  same  church  convinced  her  that  from  being  indiffer- 
ent to  his  child  he  was  becoming  unfaithful  to  his  wife. 
One  night  a  large  negro  looked  over  the  garden  wall,  and 
the  watchdog  did  not,  as  was  his  wont,  bark  at  him.  Sev- 
eral robberies  occurring  in  the  neighborhood  about  the 
same  time,  she  inferred,  ready  as  she  was  to  believe  any- 
thing that  was  bad  of  her  husband,  that  the  negro,  who 
must  have  been  one  of  the  robbers,  had  not  been  barked  at 
by  the  dog,  because  the  latter  recognized  in  him  one  of  his 
master's  confederates.  Those  who  defended  her  husband 
or  attempted  to  explain  his  actions  in  the  face  of  "such  evi- 
dence" could  only  do  so  in  the  hypothesis  that  they  had 
joined  the  conspirac)'  against  her.  Her  cousins  were  mem- 
bers of  the  conspiracy  because  a  package  of  chemises 
put  up  by  them,  which  ought  to  have  contained  a  dozen 
contained  a  lesser  number;  and  when  removed  from  her 
native  place  to  New  York  for  treatment  she  found  that  the 
custom-house  officers  had  joined  the  ranks  of  her  enemies, 
because  after  their  examination  of  the  contents  of  her  trunk 
other  articles  were  missing  or  ruined. 

The  absurdity  of  a  delusion  is  not  so  much  a  test  of  the 
absolute  mental  rank  and  the  form  of  insanity  of  a  patient, 
as  is  its  organization.  A  very  absurd  delusive  conclusion 
may  be   reached   bv  an  elaborate  and  olausibly  delivered 


THE   DELUSIONS   OF   THE   INSANE.  3I 

ratiocination,  and  a  less  absurd  delusion  may  be  formu- 
lated on  a  very  crude  process  of  reasoning. 

While  the  most  important  factors  determining  the  nature 
of  a  delusion  are  the  form  of  insanity  of  which  it  is  a  symp- 
tom and  the  manner  in  which  it  affects  the  cerebral  mech- 
anism, other  elements  must  be  admitted  to  have  some 
influence  in  tinging  it.  The  general  disposition  of  the 
patient,  whether  it  be  sanguine  or  suspicious,  will  often 
determine  the  expansive  or  persecutory  character  of  agiven 
delusion.  If  the  physical  state  is  poor  and  the  visceral 
functions  are  disordered,  hypochondriacal  delusions  are 
more  apt  to  arise  than  with  a  robust  or  fair  state  of  health. 
The  age  in  which  the  patient  lives  and  his  social  circum- 
stances have  no  inconsiderable  influence  in  the  moulding  of 
his  morbid  ideas.  With  the  development  of  republics  and 
constitutional  monarchies,  the  growth  of  the  sciences,  the 
arts,  the  press,  and  the  emancipation  of  mankind  from 
superstitious  creeds;  the  kings,  emperors,  prophets,  am- 
bassadors from  the  planets,  Holy  Virgins  and  Gods  have 
become  less  common  in  the  asylum  corridor  than  they  once 
were.  They  have  given  way  to  insane  inventors  and  com- 
munistic, journalistic,  educational,  musical,  and  scientific 
delusional  project-makers. 

The  UNSYSTEMATIZED  DELUSIONS  are  found  with  the  acute 
insanities  and  the  chronic  deteriorations.  They  may  be 
ranged  in  two  great  classes  according  as  they  are  due  to 
the  subjective  misinterpretations  arising  from  an  emotional 
disturbance,  or  the  result  of  a  destruction  of  the  logical 
associating  force.  The  delusions  of  true  melancholia  are 
instances  of  the  first  type,  those  of  paretic  dementia  of  the 
second. 

When  the  emotional  state  of  the  mclancholiac  has  over- 
whelmed the  mental  apparatus,  and  the  logical  faculty  is 
thrown  in  the  background  by  the  predominant  painful  de- 
pression, the  patient  may,  in  his  endeavor  to  account  to 
himself  for  his  painful  feelings,  in  a  vague  way  conclude 
that  he  is  a  bad  person.  Since  he  is  a  bad  person,  it  must 
be  because  he  has  committed  the  unpardonable  sin;  but  he 
cannot  tell  when  nor  why  nor  how  he  has  committed  it, 
nor  very  often  what  the  unpardonable  sin  is.  Or,  again, 
such  a  patient  feels  that  he  is  despised,  that  he  is  despised 
because  he  is  hated,  and  hallucinatory  whispers  from  all 
sides  drive  him  to  seek  relief  from  a  danger  which  was 
never  clear  in  his  own  mind,  in  suicide.     The  great  distinc- 


32  INSANITY. 

tion  between  the  systematized  delusion  of  persecution  and 
the  unsystematized  delusion  of  a  depressive  nature  is,  that 
while  the  former  is  distinct  and  fixed,  the  latter  is  vague 
and  changeable;  while  the  former  incorporates  every  present 
circumstance  in  a  pseudo-logical  chain,  the  latter  jumps 
over  the  gap;  and  while  such  logical  power  as  the  patient 
ever  had,  is  utilized  in  the  assertion  and  defence  of  the  sys- 
tematized, it  is  in  abeyance,  in  part  or  in  whole,  with  refer- 
ence to  the  announcement  and  defence  of  the  unsyste- 
matized delusions. 

The  unsystematized  delusion  of  grandeur  differs  in  a  similar 
way  from  the  systematized  expansive  delusion.  In  the  for- 
mer case — for  example,  in  paretic  dementia — the  patient  may 
assert  that  he  is  a  king  or  president,  or  that  he  has  a  million 
dollars;  because  it  is  a  desirable  thing  for  the  sanguine 
patient  to  be  a  king,  a  president,  and  to  have  money.  But 
he  will  make  no  attempt  to  explain  how  he  can  be  a  king 
and  yet  be  named  Dennis  Maginnis;  how  he  can  be  Ulysses 
S.  Grant  and  Samuel  Silberstein  at  one  and  the  same  time; 
and  why  it  is  that  he  has  a  hundred  thousand  acres  of  land 
to-day,  when  he  only  had  ten  houses  and  lots  \'esterday. 
Such  a  delusion  is  never  as  consistent  nor  expressed  with  that 
firm  conviction  that  characterizes  the  systematized  variety. 
A  systematic  delusionist  would,  if  challenged  to  explain 
why  he  answers  to  the  name  of  a  private  citizen,  when  he 
claims  to  be  a  king,  say  that  the  name  in  question  is  that  of 
the  menial  child  with  which  he  Avas  "  exchanged  while  in  the 
cradle,"  or  that  it  is  the  designation  which  he  has  adopted  to 
put  his  persecutors,  "the  agents  of  the  usurper,"  on  a  false 
track.  Again,  a  SA^stematized  delusional  lunatic,  if  claiming 
great  personal  attractions,  which  is  rare,  fortifies  his  claim  by 
letters  received, containinga"hidden  meaning"and  by  poems 
and  advertisements  "  referring  to  him."  In  paretic  demen- 
tia, with  which  affection  this  delusion  is  common,  the  patient 
will  content  liimself  with  tlie  vague  announcement  of  the 
assertion  that  he  is  handsome,  boast  that  the  women  are 
enraptured  with  him;  but  if  called  on  to  specify  he  will 
hesitate,  and  then  invent  his  grounds  as  he  goes  along — if 
able — and  forget  them  on  the  next  occasion.  Another  pa- 
retic dement  will  allege  that  he  is  five  thousand  three  hun- 
dred and  seventy-two  feet  high,  his  actual  height  being 
rather  under  five  feet  (actual  observation).  If  placed  side 
by  side  with  a  taller  man,  and  asked  to  estimate  his  size,  he 
correctly  assigns,  six  feet.     If  asked  whether  he  has  to  look 


THE   DELUSIONS   OF   THE   INSANE.  33 

up  or  down  to  measure  his  neighbor  he  unhesitatingly  ad- 
mits that  he  has  to  look  up.  But  on  being  confronted  with 
his  inconsistency,  how  it  is  possible  that  a  man  over  five 
thousand  feet  higher  than  the  tallest  giant  can  possibly 
look  up  to  an  ordinary-sized  mortal,  he  simply  reiterates 
that  he  is  so  many  thousand  feet  higher  than  the  interlocu- 
tor or  any  other  man.  A  third  person  claims  that  he  is 
General  Grant,  the  week  before  he  claimed  to  be  Roths- 
child the  banker,  but  abandoned  that  idea  when  told  that 
the  latter  Avas  dead.  He  is  unable  to  say  when  the  war 
began,  what  his  business  was  before  he  became  a  general, 
what  battles  he  fought  in,  and  finally  what  land  he  is  presi- 
dent of.  A  systematic  delusional  Ulysses  Grant  would,  in 
marked  contrast  with  the  paretic,  be  a  walking  history  of 
the  war  and  of  Ulysses  Grant;  he  would  very  probably 
content  himself  too,  with  the  more  plausible  delusion  that 
he  was  a  brother  or  intimate  friend,  or  a  subaltern  of  the 
general,  to  whom  the  latter  owed  his  "  inspiration"  and  suc- 
cess. 

While,  on  the  whole,  the  organization  of  a  delusion  reflects 
the  essential  tj'pe  of  the  insanity  of  which  it  is  a  manifesta- 
tion, it  must  be  admitted  that  there  are  special  delusions  or 
groups  of  delusions,  in  which  the  formal  contents  and  the 
superficial  guise  of  these  conceptions  have  a  diagnostic  value 
which  is  lacking  with  others.  The  delusions  of  marital  infi- 
delity and  sexual  mutilation,  when  combined,  suggest  the 
existence  of  alcoholic  insanity.  The  combination  of  unsys- 
tematized sexual  with  religious  delusions  of  a  hallucinatory 
tinge  is  characteristic  of  certain  forms  of  epileptic  insanity. 

The  current  notion,  expressed  in  several  treatises,  that 
delusions  are  independent  of  sensorial  impressions,  is  erro- 
neous. Aside  from  the  fact  that  systematized  as  well  as 
unsystematized  delusions  are  sometimes  accompanied,  and 
are  often  determined  and  modified,  by  hallucinations,*  it  is 
a  common  observation  that  visceral  illusions,  if  they  do  not 
cause,  modify  the  character  of  delusions.  Thus,  a  patient, 
in  the  writer's  observation,  who  believed  that  he  had  a  doc- 
tor in  his  belly,  was  found  to  have  extensive  peritoneal  ad- 
hesions; another,  whose  case  has  been  cited  from  Esquirol 
in  most  elementary  treatises,  had  the  notion  that  he  had  a 

*  A  case  was  recently  discussed  and  recognized  to  have  been  correctly 
observed  in  the  Medico-Psychological  Society  of  Berlin,  where  a  systema- 
tized delusion  had  developed  in  consequence  of  a  dream,  no  pre-existing- 
mental  taint  being  discoverable. 


34  INSANITY. 

council  of  bishops  in  the  same  cavity,  which  after  death  re- 
vealed the  same  pathological  condition.  The  common  de- 
lusion that  some  one  or  other  organ  or  member  has  been 
destroyed  or  petrified  or  turned  to  wood,  cork,  or  glass,  or  is 
infested  by  noisome  parasites  or  reptiles  and  maggots,  is 
probably  based  on  partial  anaesthesias  and  paraesthesias. 
Here  the  delusion  is  as  much  in  disproportion  to  the  ex- 
citing cause  as  the  idea  of  a  dreaming  person  that  he  is 
falling  down  a  great  height  is  to  the  dropping  of  his  arm 
over  the  side  of  the  bed ;  or  the  dream  of  Captain  Parry,  that 
he  was  standing  upright  with  his  feet  frozen  into  the  ice  of 
Baffin's  Bay,  was  to  the  fact  that  his  feet  were  uncovered  at 
the  time  he  had  this  dream. 

Here,  however,  as  elsewhere,  the  essential  element  is  the 
cerebral  fault  (the  logical  failure  to  correct  the  delusion, 
with  the  weakening  of  the  ego)  that  permits  the  development 
of  this  insane  symptom.  The  visceral  disease  or  the  senso- 
rial disturbance  is  an  accidental  factor  ;  the  patient  would 
be  insane  with  or  without  it,  in  the  vast  majority  of  in- 
stances; and  in  its  absence  his  defective  mind  would  fall  a 
prey  to  some  other  delusion,  under  the  assaults  of  some 
other  incidental  occurrence,  which,  equally  with  the  visceral 
disorders  alluded  to,  would  fail  to  provoke  delusions  in  a 
healthy  brain. 

The  superficial  character  of  the  delusions  of  the  chronic 
insane,  interesting  as  it  is  to  the  laity  who  visit  the  "  show- 
wards"  of  an  asylum,*  is  ordinarily  of  lesser  value  to  the 
alienist,  for  reasons  similar  to  the  ones  just  assigned.  When 
the  fiend.  Thomas,  exploded  a  dynamite  batter}^  killing 
over  a  hundred  persons  at  Bremerhaven,  a  lunatic  in  a  Ger- 
man institution  developed  the  delusion  that  the  clockwork 
of  just  such  a  battery  occupied  the  place  of  his  heart,  and 
at  a  certain  moment  would  explode  the  charge  and  destroy 
the  asylum.  When  Nobiling  shot  at  the  German  emperor 
over  a  dozen  lunatics  accused  themselves  of  complicity,  or 
offered  to  give  information  of  alleged  conspiracies  which 
they  had  unearthed.  When  the  Pope  referred  in  his  allo- 
cution to  the  Star  which  was  to  relieve  the  Church  of  its 
persecutors,  more  than  one  insane  devotee  thought  he  was 
the  one  referred  to.     Whenever  a  political  movement,  like 

*  It  was  sufficiently  evident  to  a  lunatic  described  by  Kiernan:  that 
iS         the  grosser  the  delusion  the  greater  the  interest  of  the  visitor^  and  the 
more  likely  their  donations  of  tobacco,  etc. ;  that  he  shammed  having  the 
delusion  of  "  tar  and  grease  filling  his  head  "  to  accommodate  them. 


IMPERATIVE   CONCEPTIONS.  35 

the  war  of  the  Commune,  that  of  the  Rebellion,  an  election, 
or  an  assassination,  occurs,  it  is  reflected,  caricatured,  and 
travestied  in  the  delusions  of  asylum  inmates.  The  enume- 
ration of  features  due  to  such  transient  influences,  and  re- 
vealing so  little  of  the  true  foundation  of  a  symptom,  may 
advantageously  be  waived  at  this  point. 


CHAPTER  III. 

Imperative  Conceptions  and  Morbid  Propensities. 

There  are  certain  mental  phenomena,  reflections  and  sus- 
picions arising  in  lunatics,  which,  although  they  differ  from 
the  delusion,  in  that  the  patient  is  able  to  reason  himself 
out  of  them  and  to  recognize  their  absurdity  at  times,  yet 
tyrannize  the  patient's  thoughts,  and  sometimes  his  acts,  as 
markedly  as  the  most  firmly-rooted  organized  insane  idea. 
These  phenomena  arise  suddenl}'-,  without  any  obvious  con- 
nection with  previous  thoughts;  they  appear  like  spontane- 
ous explosions  of  some  uncontrolled  segment  of  the  nervous 
system,  and  are  aptly  called  imperative  conceptions. 

On  analyzing  these  remarkable  symptoms  more  closely 
we  find  that  they  sometimes  arise  by  suggestions,  but  sug- 
gestions quite  inadequate  to  produce  such  impressions 
in  a  healthy  state.  Just  as  sane  persons  in  looking  over  a 
precipice  feel  tempted  to  precipitate  themselves  down  its 
dizzy  height,  just  as  an  eminent  savan  in  crossing  a 
bridge  was  so  strongly  tempted  to  push  a  boy  sitting  on 
the  parapet  into  the  water  below  that  he  felt  constrained 
to  turn  and  walk  away;  so  the  sight  of  a  conflagration  or  an 
execution  or  the  recollection  of  a  suicide  excites  in  the  minds 
of  the  insane,  imperative  conceptions  dictated  by  the  im- 
pressive spectacle  or  event.  A  morbid  impressibility  of  the 
nervous  system  *  may  be  reasonably  assumed  to  exist  in 
these  cases,  and  this  assumption  is  borne  out  by  the  fact 
that  imperative  conceptions  are  more  common  in  females 
than  in  males,  in  youthful  and  imbecile   than  in   aged   and 

*  The  writer  may  make  the  reservation  here  that  he  is  not  disposed  to 
admit  that  the  imitation  of  great  crimes  or  of  bloody  deeds,  in  itself,  and 
unaccompanied   by  other  evidences  of  insanity,  is  a  proof  of  its  existence. 


36  INSANITY. 

Strong-minded  persons,  and  under  such  conditions  as  preg- 
nancy, menstruation,  and  the  convalescence  from  fevers. 

Many  of  the  imperative  conceptions  remain  in  statu  quo 
for  years,  as,  for  example,  the  morbid  fear  of  places  (Agora- 
pJiobia  of  Westphal),  that  of  narrow  quarters  {ClaustroJ)/iobia), 
the  ''  Griibelsucht"  of  Griesinger,  and  the  interesting  Myso- 
pholna,  or  fear  of  defilement,  described  b}' Hammond.  One 
of  the  patients  on  whom  the  latter  author  based  his  descrip- 
tion has  since  been  under  the  writer's  care;  she  was  in 
much  the  same  condition  as  when  the  author  referred  to 
saw  her  years  before;  she  did  not  venture  to  handle  many 
articles  at  all  for  fear  of  poisoning  first  herself  and  then  her 
children  by  contact;  nor  could  she  look  at  the  wall  without 
speculating  as  to  the  dangerous  influences  which  might 
eijianate  from  it.  The  sight  of  crockery,  of  food,  of  the 
floor,  of  water,  in  short,  of  anything  connected  with  her 
household  affairs  gave  rise  to  painful  conceptions,  to  rid 
herself  of  which  she  struggled  in  vain.  In  this  case  the  the- 
ory that  the  imperative  conception  is  a  rudimentary  delusion 
seemed  to  be  borne  out;  for  the  patient  was  speculating  at 
the  time  on  the  possibility  of  the  existence  of  an  inimical  in- 
fluence against  her.  In  more  than  one  instance  the  writer 
has  observed  that  the  announcement  of  delusions  of  perse- 
cution at  the  hands  of  Jesuits,  of  Free-masons,  and  of  other 
secret  societies  was  supported  by  similar  imperative  con- 
ceptions, against  which  the  patient  had  ceased  to  struggle, 
and  which  became  in  consequence  fixed  ingredients  of  the 
delusive  belief. 

Just  as  the  insane  delusion  determines  the  development 
of  those  morbid  projects,  or  insane  enterprises,  so  character- 
istic of  many  chronic  delusional  lunatics;  so  the  imperative 
conception  often  leads  to  the  imperative  act,  or,  as  it  is 
more  commonly  called  by  English  writers,  the  morbid  im- 
pulse. But  the  imperative  act  is  directly  determined  by 
the  overpowering  conception  suggesting  it,  and  is  not  the 
result  of  a  linked  reasoning,  as  the  morbid  project  is. 

In  some  instances  the  same  morbid  impulse  recurs  again 
and  again,  or  continues  throughout  the  life  of  the  patient. 
There  are  subjects  actuated  by  a  homicidal  impulse,  slaying 
when  and  where  they  can,  while  under  the  immediate  in- 
fluence of  the  imperative  conception.  Such  persons  have 
been  styled  homicidal  monomaniacs,  unfortunately,  for  there 
is  no  such  form  of  insanity  (see  Monomania),  and  patients 
with  this  symptom  should  be  designated:   lunatics  with  in- 


IMPERATIVE  CONCEPTIONS.  37 

sane  homicidal  impulses.  The  frequency  with  which  subjects 
at  or  about  the  time  of  puberty,  epileptics  and  imbeciles, 
develop  the  impulse  to  incendiarism  has  led  to  the  erection 
of  the  group  pyromania  ;  and  the  thieving  impulse,  when  it 
exists  independently  of  any  of  tlie  commonly  recognized 
divisions  of  insanity,  is  similarly  known  as  kleptomania. 
These  and  other  terms  of  the  kind  may  continue  in  our  no- 
menclature as  symptom  designations  only, with  the  restriction 
that  they  are  to  apply  to  lunatics  in  whom  the  morbid  im- 
pulse is  the  most  prominent  and  continues  to  remain  the 
characteristic  feature  of  their  disorder.  These  terms  should 
not  be  applied  to  sufferers  from  well-marked  forms  of  in- 
sanity, such  as,  for  example,  terminal  and  paretic  demen- 
tia, which  may  manifest  themselves  in  episodial  thefts  and 
acts  of  incendiarism  or  destructiveness,  and  which  latter  are 
then  not  necessarily  impulsive  in  character. 

Pyrgmania,  or  the  morbid  impulse  to  commit  incendiar- 
ism, is  a  symptom  which  may  occur  in  epileptics  and  men- 
struating girls,  in  consequence  of  fiery  visions  or  fluxionary 
congestion;  it  may  develop  in  any  lunatic  with  destructive 
impulses,  and  is  sometimes  found  in  pregnant  and  hys- 
terical females.  It  is  usually  exhibited  at  or  shortly  after 
the  period  of  puberty,  and  as  a  rule  with  weak-minded  or 
imbecile  persons  affected  with  an  hereditary  taint  or  a  neu-* 
ropathic  constitution.  The  commission  of  a  large  number 
of  incendiary  acts  in  a  given  neighborhood,  when  not  due 
to  an  organized  movement,  to  the  desire  of  malicious  per- 
sons to  revenge  themselves,  or  to  some  other  criminal  mo- 
tive, may  be  generally  traced  to  a  patient  presenting  this 
dangerous  symptom. 

Pyromania,  like  kleptomania,  may  be  a  leading  manifes- 
tation of  periodical  insanity,  and  indeed  one  morbid  im- 
pulse, dipsomania,  has  given  its  name  to  a  variety  of  that 
disorder.     (See  Periodical  Insanity.) 

Needham  reports  a  case  where  an  educated  lady,  while 
in  the  climacteric,  developed  an  impulse  to  murder  on 
seeing  some  knives.  Recognizing  her  condition  she  volun- 
tarily went  to  an  asylum,  and  stayed  there  live  years. 

The  suicidal  and  homicidal  impulses,  based  on  the  im- 
perative conceptions  of  melancholia,  are  among  the  most 
dangerous  manifestations  of  that  disorder.  Whole  families 
have  been  immolated  in  obedience  to  these  terrible  sugges- 
tions. The  sight  of  a  revolver,  a  knife,  a  rope,  or  the  read- 
ing of  accounts  of  death  by  any  strange  or  unusual  method, 


38  INSANITY. 

is  followed  by  the  adoption  of  similar  means  calculated  to 
accomplish  self-destruction  or  the  death  of  others. 

Pregnant  women  develop  the  strangest  conceptions  and 
impulses,  often  blended  with  the  morbid  appetites  of  their 
condition.  It  seems  that  here  the  murderous  and  cannibal- 
istic impulses  are  usually  directed  against  those  nearest  and 
dearest  to  them,  on  that  same  basis  of  contrariness  which 
appears  to  govern  the  imperative  conceptions  of  the  insane 
generally,  and  the  analogous  impulses  of  the  sane,  illus- 
trated in  the  irresistible  tendency  to  laugh  while  attending 
funerals,  and  to  use  profane  expressions  in  the  midst  of 
solemn  surroundings,  which  tendencies  are  far  more  fre- 
quent than  is  ordinarily  believed. 

A  sharp  distinction  should  be  made  between  the  homi- 
cidal and  other  destructive  impulses,  and  the  morbid  propen- 
sities which  result  in  similar  acts.  The  former  are  isolated 
phenomena,  incongruous  with  the  rest  of  the  mental  sphere, 
and  the  criminality  of  the  acts,  morally  and  legally  consid- 
ered, is  recognized  after  their  perpetration.  The  latter  are 
exaggerations  of  the  propensities  which  are  either  less 
markedly  present,  or  lie  dormant  in  the  sane  mind,  or  rep- 
resent psychical  atavisms.  The  lunatic  affected  with  the 
^//a.y/-instinctive  propensity  to  murder,  to  eat  human  flesh, 
or  to  indulge  in  abnormal  sexual  acts,  if  confronted  with 
the  enormity  of  his  inclinations,  may  recognize  their  tech- 
nical illegality,  but  in  his  own  mind  he  feels  no  contrition 
for  the  act  in  itself,  and  considers  himself  justified  in  fol- 
lowing his  inclinations  whenever  he  can  safely  do  so,  and 
finds  a  favorable  opportunity. 

Morbid  propensities  and  impulses  are  sometimes  com- 
bined, as  in  the  cases  of  pregnancy  alluded  to. 

The  morbid  propensities  are  frequently  confounded  with 
the  imperative  conceptions,  because  they  lead  to  similar 
results,  and  because,  as  in  the  cases  referred  to,  they  occa- 
sionally coexist.  They  probably  depend  on  analogous 
fundamental  states,  but  differ  in  being  more  firmly  rooted 
in  the  patient's  organization;  they  are  perversions  of  those 
instinctive  tendencies  which  are  common  to  mankind,  and 
they  control  the  individual  in  an  analogous  manner  to,  but 
usually  more  intensely  than  the  physiological  desires. 

The  morbid  propensities  are  perversions  of  the  two  main 
instinctive  tendencies  of  the  human  race:  the  desire  for 
food  and  the  sexual  appetite.  In  maniacal  and  hysterical 
conditions  the  sexual  appetite  may  be  exaggerated  to  a  re- 


IMPERATIVE   CONCEPTIONS.  39 

markable  degree,  constituting  satyriasis  in  the  male,  and 
nytnphoma/iia  in  tlie  female.  The  patient  suffering  from  the 
former  condition  may  commit  rape,  resort  to  indecent  ex- 
posure of  his  person,  and  make  insulting  proposals  to 
females;  while  the  nymphomaniac,  aside  from  her  solicita- 
tion of  male  persons  and  masturbation,  may  reveal  her 
state  of  mind  by  extravagances  in  dress,  courtesan-like  be- 
havior, and  a  tendency  to  make  obscene  accusations  against 
other  females,  less  for  the  sake  of  injuring  these  than  for 
the  purpose  of  suggesting  to  the  interlocutor  what  her  own- 
desires  are. 

It  should  be  recollected,  however,  in  estimating  the  mo- 
tives of  a  female  patient  manifesting  exaggerated  sexual 
ideas,  that  these  are  not  necessarily  of  a  character  looking 
to  animal  gratification.  In  insanity  we  find  every  analogy 
of  mental  health;  and  just  as  a  large  number  of  perfectly 
healthy  women  are  devoid  of  a  sexual  appetite,  or  manifest 
but  feeble  indications  of  it,  so  we  have  occasion  to  observe 
female  patients  whose  conduct,  while  corresponding  in  the 
main  features  to  that  of  the  nymphomaniac,  does  not  cul- 
minate in  attempts  at  sexual  acts.  Such  patients  are  very 
likely  to  develop  platonic  admiration  for  male  and  even 
female*  persons,  or  to  become  religious  devotees  or  en- 
thusiasts. All  through  the  history  of  insanity  the  student 
has  occasion  to  observe  this  close  alliance  of  sexual  and 
religious  ideas;  an  alliance  which  may  be  partly  account- 
ed for  because  of  the  prominence  which  sexual  themes 
have  in  most  creeds,  as  illustrated  even  in  ancient  times  by 
the  Phallus-worship  of  the  Egyptians,  the  ceremonies  of 
the  Friga  cultus  of  the  Saxons,  the  frequent  and  detailed 
leference  to  sexual  topics  in  the  Koran  and  several  other 
books  of  the  kind;  and  which  is  further  illustrated  in  the 
performances  which,  to  come  down  to  a  modern  period, 
characterize  the  religious  revival  and  "camp-meeting,"  as 
they  tinctured  their  mediaeval  model,  the  Miinster  anabap- 
tist movement. 

The  most  iimportant  morbid  propensities,  from  a  medico- 
legal point  of  view,  are  the  sexual  perversions  and  anthro- 
pophagy. Instances  of  these  remarkable  conditions  are  col- 
lected in  Caspar's  treatise  on  forensic  medicine  ;  but  our 

*The  case  of  an  acutely  maniacal   patient  who  fell   in   love  with  her 
nurse,  related  by  Krafft-Ebing  in  the  Archiv  f.  Fsychiarie,  seems  to  the         '^  /_ 
writer  to  belong  to  this  category,  and  not  to  be  strictly  one  of  sexual  per- 
version. 


40  INSANITY. 

more  perfect  knowledge  of  their  pathological  nature  we 
owe  to  Krafft-Ebing. 

While  sodomy,  pederasty,  and  other  disgusting  abuses 
of  the  sexual  apparatus  were  common,  and  even  cultivated 
by  more  than  one  nation  of  antiquity,  and  are  such  every- 
day occurrences  in  Armenia,  S3^ria,  the  home  of  the  ancient 
corybanthism,  and  in  other  Oriental  lands  to-day  as  to  be 
there  considered  legitimized  by  custom — not  to  mention 
the  fact  that  they  are  too  common  in  our  large  cities  to  be 
considered  anything  beyond  the  outcome  of  salaciousness, 
idleness,  and  opportunities  created  by  that  over-fed  luxury 
which  tires  of  natural  gratification — there  are  individual 
cases  where  these  acts  must  be  regarded  as  the  imperative 
results  of  a  faulty  organization. 

In  these  instances  there  are  sometimes  physical  signs  such 
as  asvmmetry  or  other  malformation  of  the  skull,  deformi- 
ties of  the  ears,  and  notably  of  the  sexual  organs,  which  in- 
dicate the  organic  nature  of  the  perversion;  and,  it  may 
be  added,  which  exemplify,  the  close  relation  existing  be- 
tween the  development  of  the  nerve-centres  and  the  sexual 
apparatus.  The  existence  of  these  signs  in  some  cases 
points  to  a  deep  error  in  development,  dating  from  an  early 
embryonic  period.  Such  a  developmental  fault  may  be  as- 
sumed, by  analogy,  to  exist  in  a  lesser  degree  in  those  sub- 
jects which  do  not  exhibit  external  signs.  Searching  inquiry 
generally  reveals  other  anomalies  in  the  nervous  functions, 
and  although  these  sexual  perversions  have  occasionally 
been  noted  in  persons  of  fair  and  even  good  intellectual 
powers,  they  are  generally  associated  with  more  or  less 
mental  weakness. 

A  curious  contribution  to  the  discussion  of  this  question 
was  made  by  an  intelligent  judicial  officer  named  Ullrich, 
who  himself'afflcted  with  that  form  of  this  perverse  tenden- 
"cy,  in  which  sexual  love  is  displayed  toward  the  same  sex, 
wrote  a  book  in  its  defence,  claiming  that  it  is  justified  by 
natural  laws,  inasmuch  as  it  occurs  as  a  zoological  phenom- 
enon in  certain  insects;*  and  he  fortified  his  position  in  a 
most  elaborate  manner  by  the  precedents  furnished  by  the 
classical  nations  of  antiquity.  Such  cases  as  his  strongly 
sustain  Westphal's  claim  that  sexual  perversion  is  not  nec- 

*  Among  Coleoptera.  It  may  be  not  unrelated  to  this  question  that  the 
phenomenon  of  a  union  of  both  sexes,  in  such  a  way  that  one  lateral  half 
of  the  animal  is  male  and  the  other  female,  or  where  alternate  quarters 
are  of  opposite  sexes,  is  most  frequent  in  this  order  of  insects. 


IMPERATIVE   CONCEPTIONS. 


41 


essarily  and  by  itself  a  proof  of  insanity,  as  some  have  be- 
lieved. 

The  most  common  form  of  pathological  sexual  perver- 
sion is  the  love  of  the  same  sex.  The  male  subjects  are  as 
a  rule  peculiar  from  boyhood  up,  manifest  feminine  tenden- 
cies, have  a  mincing  gait,  prefer  dolls  and  girlish  toys  to 
boyish  sports,  delight  in  assuming  the  female  costume,  and 
develop  platonic  and  sexual  love  for  persons  of  the  same 
sex.     Seminal  emissions  and  even  the  full  orgasm  are  pro- 


FlG.  I. 

voked  by  a  grasp  of  the  hand  or  an  embrace  of  the  adored 
s«-bject;  and  so  far  as  the  recorded  cases  go,  the  subjects 
repudiate  the  idea  that  they  are  guilty  of  ^pe4erag ty-  w i th  dis- 
gust and  indignation,  their  modus  operandi  consisting  in 
mutual  titillation.  Cryptorchidism,  hypospadias,  defective 
development  of  hair  on  the  pubes  and  face,  club-foot, 
and  other  signs  of  imperfect  development,  are  often  found 
here,  and  a  feminine  expression  is  very  common. 

An  historical  instance  of  this  form  of  perversion  is  that  of 
Lord  Cornbury,  a  cousin  of  Queen  Anne,  and,  as  the  son  of 


42  INSANITY. 

Lord  Clarendon,  afterwards  a  member  of  the  House  of 
Lords,  also  at  one  time  governor  of  the  colony  of  New  York. 
This  person,  whose  picture,  preserved  in  the  library  of  the 
N.  Y.  Historical  Society,  illustrates  the  asymmetry  and 
feminine  appearance  natural  to  and  the  costume  adopted 
by  such  subjects  (Fig.  i),  was,  according  to  his  historian, 
a  degraded  and  hypocritical  being,  utterly  devoid  of  a 
moral  sense,  and  so  thoroughly  mean  and  contemptible  that 
in  a  short  time  all  classes  of  the  population  were  arrayed 
against  him,  compelling  his  removal.  His  greatest  pleas- 
ure was  to  dress  himself  as  a  woman,  and  the  good  citizens 
of  New  York  frequently  saw  their  governor,  the  commander 
of  the  colonial  troops  and  a  scion  of  the  royal  stock,  prome- 
nading the  walls  of  the  little  fort  at  the  Bowling  Green,  with 
all  the  coquetry  of  a  woman  and  the  gestures  of  a  courtesan. 

We  have  less  knowledge  of  sexual  perversion  of  this  va- 
riety in  the  female  sex;  though  the  accounts  of  "Lesbian 
love"  would  seem  to  indicate  its  existence  in  antiquity. 
The  writer  has  now  under  observation  a  lady  suffering  from 
periodical  insanit}',  who  has  an  intense  but  pure  affection 
for  a  lady  companion  whom  it  is  necessary  to  allow  her  to 
have  to  manage  her  outside  of  an  asylum. 

The  second  variety  comprises  cases  where  sexual  grati- 
fication, while  resorted  to  with  persons  of  the  opposite 
sex,  is  accompanied  by  cannibalistic  or  analogous  perverted 
desires.  Several  of  the  Caesars,  a  family  which  presented  nu- 
merous examples  of  transmitted  mental  disorder,  delighted 
in  seeing  maidens  slaughtered  from  sexual  motives.  More 
recent  instances  have  been  adduced  by  Lombroso,  and  at  the 
present  moment  the  province  of  Westphalia  is  excited  over 
the  commission  of  more  than  a  score  of  murders,  performed 
in  the  most  revolting  manner,  on  young  girls  who  had  been 
previously  violated,  every  indication  pointing  to  the  same 
person  as  the  perpetrator.* 

*  One  of  this  class  of  instinctive  butchers  made  the  following  statement 
regarding  the  murder  of  one  of  his  long  series  of  victims,  who  was  first 
violated  and  then  treated  in  the  manner  detailed  by  himself:  "I  first 
opened  her  chest,  and  divided  the  fleshy  parts  of  her  body  with  a  knife. 
Then  I  dressed  this  person,  as  a  butcher  dresses  cattle,  and  chopped  her 
body  into  pieces,  so  as  to  get  them  into  a  hole  which  I  had  dug  on  the 
mountain.  I  can  say  that  while  opening  the  body  I  felt  so  ravenous  that 
I  trembled,  and  cut  out  and  ate  a  piece."  Others  have  torn  out  the 
heart,  and  drunk  the  blood  of  their  victims,  and  Tirsh  (reported  by  Masch- 
ka)  cut  off  the  breasts  and  genitals  of  an  old  woman  whom  he  had  killfcf] 
and  (violcued,  and  cooked  and  devoured  these  parts. 


HALLUCINATIONS   AND    ILLUSIONS.  43 

It  is  to  be  insisted  here  that  even  these  terrible  sexual 
aberrations  may  exist  as  combined  results  of  a  vicious  incli- 
nation and  cynical  brutality  in  persons  not  insane.  The 
term  Anthropophagy,  as  indicating  a  morbid  perversion  of  the 
sexual  appetite,  calling  for  the  satisfaction  of  murderous  and 
cannibalistic  desires,  should  be  limited  to  those  cases  where 
there  are  signs  of  heredity,  somatic  evidences  of  degenera- 
tion, and  other  manifestations  of  a  faulty  nervous  system.  In 
one  such  case,  the  executed  monster  Leger,  Esquirol  found 
gross  brain  disease  of  the  kind  sometimes  discovered  in  the 
insane. 

Necrophilism  is  a  name  given  to  the  propensity  to  violate 
dead  bodies,  which  in  very  rare  instances  is  found  as  a  man- 
ifestation of  periodical  insanity.  The  French  Sergeant  Ber- 
trand,  who  broke  into  churchyards,  under  great  risks,  and 
dug  up  female  bodies  to  violate  and  mutilate  them,  is  a 
case  in  point.  In  this  instance  the  hereditary  history,  the 
periodical  recurrence,  and  the  association  of  this  frightful 
propensity  with  signs  of  maniacal  excitement  demonstrated 
the  insanity  of  the  individual.  But  there  could  be  no  bet- 
ter exemplification  of  the  doctrine  that  few  acts,  however 
extravagant,  are  in  themselves  signs  of  insanit}^  than  that 
this,  the  most  incomprehensible  of  all  conceivable  crimes, 
like  Anthropophagy,  has  been  committed  by  persons  whose 
sanity  could  not  be  disputed. 


CHAPTER  IV. 

Hallucinations  and  Illusions. 

Hallucinations  and  illusions  are  erroneous  perceptions 
sometimes  occurring  within  tlie  limits  of  health,  but  in  their 
more  intense  development  characteristic  of  certain  forms  of 
mental  disturbance.  Here,  as  elsewhere,  it  is  the  manner 
in  which  the  symptom  originates,  the  basis  on  which  it  de- 
velops, and  the  relation  it  assumes  toward  the  ego  that  de- 
termines its  interpretation  by  the  alienist. 

An  hallucination  is  the  perception  of  an  object  as  a  real  pres- 
ence, withotit  a  real  presence  to  justify  the  perceptiofi.  The  per- 
c^tion  of  a  heavenly  vision  by  the  religious  lunatic,  the 
odor  of  putrefying  and   other  disgusting  substances  com- 


44  INSANITY. 

plained  of  by  hypochondriacal  and  demented  paretic  pa- 
tients, the  voices  commanding  the  sacrifice  of  relatives  or 
self  to  insane  fanatics,  and  those  driving  the  melancholiac 
to  the  commission  of  suicide,  are  among  the  more  charac- 
teristic examples  of  hallucinations  in  the  insane.  In  all 
these  cases  there  are  no  objective  grounds  for  the  percep- 
tion. 

An  illusion  is  the  perception  of  afi  object  actually  present,  but  in 
characters  which  that  object  does  not  really  possess.  The  delu- 
sion of  a  hypochondriacal  patient  that  he  is  decaying,  be- 
cause he  detects  a  decaying  smell,  while  there  is  in  reality  a 
chronic  catarrh  of  his  naso-pharyngeal  passages,  resulting 
in  a  bad  though  not  a  putrid  odor,  is  founded  on  an  illu- 
sion ;  the  patient  who,  hearing  the  wagons  rolling  on  a  street 
imagines  that  his  name  is  being  repeated  in  regular  rhythm, 
has  illusions;  and  the  melancholiac  who,  seeing  the  appre- 
hensive glances  of  his  relatives,  imagines  that  they  sneer  at 
and  threaten  him,  is  suffering  from  the  same  class  of  symp- 
toms. In  short,  while  the  hallucination,  as  far  as  the  outer 
world  is  concerned,  is  a  creation  out  of  nothing  and  entire- 
ly fictitious,  the  illusion  is  but  a  misinterpretation  of  a  phy- 
siological impression  and  has  a  partial  basis  in  fact. 

In  the  strictest  psycho-physiological  sense  an  hallucina- 
tion is  a  morbidly  intensified  memory.  Gray  nervous  mat- 
ter, wherever  situated,  if  connected  with  a  sensory  periph- 
ery, is  capable  of  receiving  and  retaining  impressions.  The 
length  of  time  through  which  the  impression  may  be  re- 
tained differs  in  different  segments  of  the  central  nervous 
apparatus.  When,  for  example,  a  person  looks  at  a  window 
with  a  black  figure  standing  in  front  of  it  distinctly  out- 
lined against  a  very  bright  sky,  and,  after  regarding  it  for  a 
certain  length  of  time  fixedly,  shuts  his  e)'es  and  turns 
away,  he  will  find  the  image  still  continuing.  It  gradually 
becomes  fainter,  but  may  last  for  several  minutes.  The 
fact  that  the  retinal  "  after-image"  follows  the  movements  of 
the  eyeball  shows  that  it  has  its  seat  in  the  retina,  and  proves 
that  the  ganglionic  cell  layer  of  that  ocular  tunic  is  capable 
not  only  of  receiving  impressions  but  also  of  retaining  them 
for  a  brief  period  of  time.  Now  let  a  person  be  immured 
in  absolute  darkness  for  a  week;  let  him,  without  exposing 
his  retina  to  any  other  impression,  repeat  the  experiment, 
and  it  will  be  found  that  the  retinal  after-image  will  last 
very  much  longer!  In  short,  the  less  the  nerve-cells  of  the 
retina  are  subjected  to  the  rapidly-succeeding,  quickly-inter- 


HALLUCINATIONS   AND   ILLUSIONS.  45 

rupted,  and  ever-changing  impressions  of  the  outer  world, 
the  better  becomes  its  registration  power.  It  is  because  of 
the  multitude  of  impressions  crowding  and  jostling  each 
other  and  involving  the  same  retinal  elements  over  and 
over  again,  that  it  becomes  unfitted  to  retain  impressions 
longer,  and  the  incapacity  is  in  this  case  a  beneficial  one. 

But  there  is  an  area  in  the  brain — the  cortex  of  the  calca- 
rine  fissure,  its  neighborhood,  and  a  considerable  extent  of 
the  convexity  of  the  occipital  and  possibly  of  the  parietal 
lobes — which  is  known  to  be  the  central  abutment  of  fibres 
connected  with  the  optic  tracts.  A  host  of  anatomical  and 
pathological  observations  support  this  assertion.  Here  we 
find  that  the  cortex  has  a  structure  differing  materially  from 
that  of  the  rest  of  the  cerebrum,  and  indeed,  as  Meynert 
pointed  out,  one  not  without  some  analogies  to  that  of  the 
retina  itself. 

Here  the  impressions  occurring  in  the  retina  and  trans- 
mitted through  the  optic  nerves,  tracts,  and  radiations,  are 
registered  as  memories.  It  is  because  the  cortical  nervous 
elements  are  much  more  numerous  than  those  of  the  retina  * 
and  that  the  same  cells  and  groups  of  cells  are  not  called 
upon  to  serve  as  recipients  so  often,  that  visual  memories  diXO. 
more  permanent  than  the  after-images. 

Memories  depend  for  their  fixation  on  three  factors:  the 
intensity  of  the  impression,  the  frequency  with  which  it  re- 
curs, and  the  functional  disposition  of  the  central  nervous 
elements  at  the  time  of  the  impression.  The  same  laws 
that  govern  the  after-image  also  govern  its  more  stable 
analogue,  the  memory.  Just  as  a  brilliant  illumination  is 
more  certainly  followed  by  an  after-image  than  a  feeble  one; 
so  a  prominent  fact,  overwhelming  or  crowding  out  less  im- 
portant collateral  circumstances,  is  more  apt  to  become 
fixed  in  the  memory  than  the  latter.  Just  as  the  retina, 
after  a  long  period  of  inactivity,  is  more  sensitive  in  relation 
to  after-images;  so  the  cortex  of  the  youth,  of  him  who 
awakes  from  a  refreshing  slumber,  or  who  has  been  idle, 
is  better  fitted  to  register  new  impressions  than  the  cortex 
of  the  aged,  of  him  who  is  fatigued,  or  has  been  straining 
his  memory  for  some  time. 

If  a  person  presses  a  pin's  head  against  any  part  of  the 
closed  eye  he  will  see  a  corresponding  spectre,  apparently 

*  And  that  the  numerous  associating  tracts  present  a  basis  for  a  greater 
number  of  association  possibilities. 


46  INSANITY. 

on  the  other  side  of  the  field  of  vision.  If  he  uses  a  trian- 
gular, a  circular,  or  a  perforated  object,  the  image  will  have 
the  corresponding  shape;  and  in  the  same  way  the  appar- 
ent situation  and  number  of  the  impressions  may  be  varied. 
This  experiment,  like  the  fiery  visions  noted  by  patients  who 
are  suffering  from  pathological  changes  in  the  retina,  shows 
that  impressions  may  be  produced  simulating  those  ordi- 
narily resulting  from  the  impressions  of  the  outei"  world, 
by  non-physiological  irritation  of  gray  matter. 

Just  as  the  spectre  produced  by  pressure  on  the  eye  is  an 
artificial  imitation  of  the  retinal  after-image,  so  the  hallu- 
cination is  a  morbid  intensification  of  a  memory,  produced 
by  the  irritation  of  the  registration  field  of  that  memory. 

Just  as  the  irritation  whose  result  imitates  the  true  reti- 
nal light  impression  is  applied  at  the  normal  site  of  such 
light  impressions,  so  the  irritation  resulting  in  an  halluci- 
nation must  be  directed  to  the  normal  centre  of  the  mem- 
ory registrations — in  other  words,  to  the  brain  cortex  or  its 
subsidiary  depots. 

Just  as  the  physiological  irritation  is  competent  to  repro- 
duce old  recollections,  through  a  healthy  use  of  the  associa- 
tion tracts,  and  the  consequent  increase  of  the  nutritive  and 
bio-chemical  changes  in  a  given  cortical  or  sub-cortical  ner- 
vous area;  so  a  meningitis,  a  toxic  agent,  a  relative  hyper- 
aemia,  or  some  other  profound  nutritive  disturbance  of  the 
same  area,  will  produce  the  same  result  ///  kind,  but  so 
much  more  intense  /;/  degree,  that  the  reawakened  impres- 
sion, instead  of  being  of  the  ordinary  intensity  of  the  mem- 
ory, becomes  lifelike  and  simulates  a  real  impression.* 

Within  the  limits  of  health  hallucinations  are  usually  lim- 
ited to  those  occurring  during  sleep,  in  the  course  of  dreams, 

*  According  to  Meynert  a  reversal  of  the  normal  course  of  impressions 
takes  place  in  addition;  the  pathological  irritation  extends  centrifugally 
toward  the  periphery,  and,  transmitted  to  the  peripheral  sense-organs,  de- 
termines the  lifelike  reality  of  the  hallucination.  There  are  grounds  for 
this  belief;  but  the  secondary  irritation  of  the  sensory  periphery  is  not 
essential:  some  of  the  most  elaborate  hallucinations  occur  in  persons 
who  have  had  their  eyeballs  extirpated,  and  the  writer  has  made  \.he  post- 
mortem examination  in  a  case  where  the  most  marked  and  complicated  hal- 
lucinations of  vision,  the  Deity, angelic  processions, worms  in  the  food,  etc., 
occurred  siib  Jijiem,  the  optic  nerves  being  found  cut  in  two  by  the  pressure 
of  a  tumor  and  the  thalamus  softened,  leaving  the  cortex  alone  to  serve 
as  the  basis  of  the  symptoms.  Hallucinations  may  originate  in  thalamic 
disease  or  disturbance  anywhere  along  the  course  of  the  optic  fibres,  but 
their  entry  into  the  consciousness  can  onlj-  take  place  in  the  cortex. 


HALLUCINATIONS   AND   ILLUSIONS,  47 

or  in  the  intermediate  state  of  sleeping  and  waking.  If  the 
observation  of  Treviranus,  made  on  a  patient  whose  brain 
surface  was  exposed,  that  the  brain  surface  is  paler  in  sleep 
than  in  the  waking  condition,  but  richer  in  blood  during 
sleep  interrupted  by  dreams  than  in  dreamless  sleep,  is 
confirmed,  we  shall  have  to  look  to  irregularities  in  the 
blood-supply  as  the  source  of  the  hallucination  in  the  in- 
sane. The  fact  that  musicians  are  more  apt  to  have  hallu- 
cinations of  hearing,  painters  and  sculptors  those  of  sight, 
microscopists  those  of  the  objects  which  they  study,  would 
seem  to  indicate  the  potency  of  excessive  physiological 
irritation  to  predispose  to  the  production  of  the  same  phe- 
nomena as  those  resulting  from  pathological  irritation. 
Here  again  the  analogy  between  the  extra-physiological  phe- 
nomena occurring  within  the  limits  of  sanity  and  those  char- 
acteristic of  insanity  is  manifested.  The  hallucinations  of 
the  insane,  generally  relate  to  familiar  objects,  to  those 
which  the  patient  has  been  in  daily  contact  with,  or  which 
are  connected  in  some  way  with  his  dominant  conceptions. 
The  hallucinatory  religious  monomaniac  sees  the  gates  of 
heaven  ajar,  St.  Peter  beckoning,  processions  of  angels  and 
saints,  the  crucifixion;  or,  on  the  other  hand,  the  devil 
with  myriads  of  imps  dancing  round  and  mocking  him,  the 
visions  of  St.  Anthony  repeated,  or  the  strange  beasts  de- 
scribed with  so  little  reference  to  zoological  harmony  in 
the  "  Revelations."  The  insane  claimant  of  a  throne  hears 
encouraging  or  threatening  comments  on  his  claim,  sees 
detectives  dogging  his  footsteps,  or  has  visions  of  great 
state  receptions.  The  lunatic  with  sexual  ideas  sees  images 
of  the  most  voluptuous  kind.  The  hypochondriacal  lunatic 
sees  his  skull  open,  fungous  growths  on  his  brain,  his  vis- 
cera exposed,  the  liver  riddled  with  abscesses,  and  other 
morbid  conditions,  varying  with  the  extent  of  his  reading 
and  experience  of  diseases. 

It  is  in  consonance  with  the  same  fact  that  insane  hallu- 
cinations vary  in  different  races  and  communities,  and  with 
different  periods  of  history,  like  the  dreams  and  delusions 
of  the  day  and  the  people.  The  visionary  lunatic  of  ancient 
Greece  saw  the  gods  and  goddesses,  or  satyrs,  dryads,  and 
nymphs  peopling  the  forests;  he  of  the  middle  ages  com- 
muned with  saints,  or  saw  the  devil,  in  the  fashion  of  that 
day,  with  horns,  a  goat's  beard,  a  barbed,  arrow-headed  tail 
and  a  pitchfork;  to-day  the  visions  of  heaven  and  hell  are 
more  after   Banyan's  style  or   Miltonic  in   character;  and 


48  INSANITY. 

with  the  practical  tendencies  of  our  growing  civilization  they 
are  undoubtedly  becoming  rarer  than  they  once  were. 

The  discrimination  between  the  insane  illusion  and  the 
insane  hallucination  cannot  always  be  sharply  made.  In- 
deed, within  the  realm  of  sanity  the  two  are  noted  to  run 
into  each  other.  What  is  generally  considered  the  best  ex- 
ample of  hallucinations  in  the  sane,  the  vision  of  a  dream, 
is  probably  in  part  illusional.  Schemer  has  shown  that  with 
the  majority  of  dreams  involving  visions  and  conceptions 
of  water  the  urinary  bladder  is  full;  where  there  is  a  feeling 
of  looking  or  falling  down  a  dizzy  height  the  stomach  is 
disturbed,  and  here  a  centripetal  influence  analogous  to  that 
transmitted  by  the  vagus  and  determining  a  subjective  diz- 
ziness in  gastric  disorder,  is  undoubtedly  produced.  The 
dream-visions  of  luxurious  banquets  are  generally  refer- 
able to  a  sense  of  hunger;  and,  as  showing  that  the  mild 
irritations  which  determine  the  illusional  hallucinations  of 
sleep  when  exaggerated  may  provoke  them  in  the  waking 
state,  we  need  but  refer  to  the  numerous  instances  where 
shipwrecked  or  other  travellers,  after  a  long  period  of 
starvation,  fell  into  a  delirium  tinged  by  similar  visions.* 
Among  the  insane  there  are  similar  transitions  between 
the  pure  hallucination,  the  illusional  hallucination,  and  the 
pure  illusion. 

While  disturbances  of  the  visceral  or  general  sensations 
ma}'^  determine  hallucinations  having  a  certain  semblance 
of  the  real  about  them,  like  those  just  cited,  there  is  another 
class  which  presents  less  of  the  systematic  and  plausible 
character.  These  are  visions  of  innumerable  objects  of  the 
same  kind  :  insects,  fish,  worms,  maggots,  snowflakes,  or 
sounds  of  a  hundred  bells,  a  thousand  whispers.  In  the 
dreamy  state  such  hallucinations  are  probably  referable  to 
"  luminous  dust"  impressions  flitting  before  the  closed  eye 
and  tinnitus  aurium  as  their  starting  point;  in  a  diseased 
state  they  imply  a  deep  nutritive  or  toxic  disturbance  in  the 

*A  few  years  ago  several  lumbermen  lost  their  way  on  the  ice  of 
Lake  Ontario,  and  were  found  on  a  little  island,  from  which  it  was  diffi- 
cult to  remove  them  owing  to  the  attractive  vision  of  a  splendid  feast  and 
a  warm  fire  which  occupied  the  minds  of  these  persons,  who  had  almost 
reached  the  point  of  death  from  cold  and  starvation  combined.  This 
winter  two  teamsters  lost  their  way  in  the  snows  of  Montana.  Both  were 
saved  by  the  pluck  and  wood-craft  of  one  of  them,  but  he  experienced 
great  difficulty  in  preventing  his  comrade  from  darting  away  into  the 
woods,  where  he  claimed  stood  a  man  with  a  basket  of  provisions  and  a 
house  with  lights  from  which  proceeded  the  noise  of  a  carousal. 


HALLUCINATIONS   AND   ILLUSIONS.  49 

brain  itself.  Hallucinations  of  this  kind  are  common  feat- 
ures of  opium  and  alcoholic  delirium,  of  the  delirium  of 
meningitis,  of  the  visions  of  the  paretic  dement,  and  are  in 
these  two  latter  disorders  of  grave  import. 

It  is  difficult  to  determine  to  what  extent  hallucinations 
in  the  insane  are  determined  in  their  origin  and  recurrence 
by  the  faulty  conceptions  and  reasoning  of  the  patient. 
There  are  undoubtedly  patients  suffering  from  delusional 
insanity  whose  hallucinations  are  a  sequel  of  their  delu- 
sions. Just  as  some  artists  possess  the  power  of  almost 
hallucinating  a  face  once  seen,  and  faithfully  transferring 
its  lineaments  to  canvas,  or  as  Goethe,  absorbed  in  selfish 
reveries,  suddenly  saw  himself  before  him  on  the  road;  so 
the  delusional  lunatic,  intensely  concentrating  his  morbid 
ideation  in  a  religious,  an  erotic,  an  ambitious,  a  hypochon- 
driacal, or  a  persecutory  notion,  develops  corresponding 
hallucinations.  Inasmuch  as  the  hallucination  strengthens 
and  confirms  the  delusion  opinion  out  of  which  it  grows, 
the  grave  signification  of  this  complicating  symptom  in 
the  chronic  insane  becomes  evident. 

Again,  there  are  cases  where  the  hallucination  determines 
the  character  of  a  subsequent  delusion,  just  as  there  are  a 
few — a  very  few — authentic  instances  where  a  dream  has 
produced  an  insane  delusion.  Insanity  of  this  character,  as 
a  rule,  offers  a  better  prospect  than  that  where  the  delusion 
is  a  primary  factor,  and  determines  the  development  of, 
and  becomes  in  turn  confirmed  and  more  firmly  organized 
by  the  hallucinations  it  provokes. 

Hallucinations  are  found  with  most  forms  of  insanity, 
but,  being  often  of  a  more  evanescent  character  than  delu- 
sions, they  are  not  as  frequently  noted;  they  are  also  less 
readily  announced,  either  because  the  patient  imagines 
that  the  visions  and  voices  are  of  a  sacred  character,  and 
that  it  would  be  therefore  a  sin  to  communicate  them  to 
the  "  uninitiated,"  or  because  some  unwise  person,  having 
previously  ridiculed  him,  the  patient,  insane  as  he  is,  appre- 
hends that  his  tale  will  be  treated  as  a  fiction  again.  There 
is,  however,  one  form  of  insanity  in  wliich  liallucinations 
are  so  prominent  and  numerous  that  it  has  been  termed 
"hallucinatory  confusion."  Hallucinations  are  also  char- 
acteristic of  insanity  developing  in  prisoners,  and  are  here 
doubtless  due  to  the  favoring  influence  of  darkness,  solitude, 
and  silence  in  producing  hallucinatory  phenomena.  The 
same  remark  applies  to  the  insanity  of  blind  persons. 


■50  INSANITY. 

The  true  signification  of  insane  hallucinations  and  illu- 
sions,  like  that  of  the  insane  delusion,  lies  in  the  fact  that 
the  logical  apparatus,  instead  of  correcting  the  error  of  the 
perceptions  by  the  inhibitory  influence  of  collateral  percep- 
tions and  reasoning,  incorporates  them  in  an  insane  belief, 
or  bases  insane  actions  on  them. 

In  briefly  enumerating  the  varieties  of  insane  percep- 
tions, it  is  best  to  consider  hallucinations  and  illusions  tO' 
gether. 

Visual  hallucinations,  or  insane  visions,  may  vary  in  in- 
tensity and  distinctness  from  mere  blurs,  clouds,  or  haloes,  to 
flashes  of  light,  bright  color  perceptions  and  fac-sifniles  of 
the  reality.  The  perception  of  single  faces  and  figures  often 
engaged  in  some  occupation,  the  details  of  dress  and  of  the 
features  being  distinctly  reproduced;  or  of  noisome  reptiles 
or  dancing  devils  in  larger  numbers  and  lesser  distinctness 
serve  to  characterize  different  varieties  of  insanity.  Some- 
times the  same  hallucination  continues  for  years.  A  patient 
may  see  the  same  person  or  animal  following  him  wherever 
he  goes.  At  others  a  fixed  hallucination  may  become  the 
basis  for  transitory  ones.  A  patient  sees  himself  in  heaven 
or  in  hell  continuousl)%  but  the  other  inhabitants  of  the  hal- 
lucinated locality  are  continualh'  changing.  In  their  com- 
plexity and  expansiveness  such  hallucinations  sometimes 
approach  the  abstract  visions  of  the  poet.  This  variety  is 
found  in  chronic  insanity,  and  is  less  favorable  in  its  prog- 
nostic indications  than  the  more  confused  and  evanescent 
hallucinations  of  some  acute  derangements. 

Illusions  of  sight  general!}'  relate  to  persons,  and  are  like 
the  corresponding  hallucinations  determined  by  pre-existing 
delusions.  Either  the  patient  refuses  to  recognize  his  rela- 
tives (generally  one),  and  asserts  that  they  are  strangers,  or 
— and  this  is  a  not  uncommon  occurrence  in  the  asylum  ward 
— greets  and  embraces  others  as  his  or  her  children,  sisters, 
brothers,  or  parents.  These  combined  illusions  and  delu- 
sions of  identity  are  so  powerful,  that  in  one  instance  a 
patient  who  asserted  that  the  writer  was  her  son,  though 
properly  recognizing  all  her  other  surroundings,  and  very 
unmanageable  generally,  followed  his  directions  and  volun- 
tarily went  to  the  asylum,  because  she  could  not  believe  her 
own  son  would  advise  her  against  her  and  his  interests. 

Hallucinations  of  hearing  are  more  frequent  in  chronic 
delusional  insanity  and  in  melancholia,  than  those  of  sight, 
and  are  particularly  common  in  persecutor}'  delirium.     Not 


HALLUCINATIONS   AND    ILLUSIONS.  5 1 

infrequently,  hallucinations  of  vision  and  those  of  hearing 
coexist.  A  melancholiac  sees  and  hears  those  who  are 
mocking  and  pursuing  him;  the  chronic  delusional  lunatic 
sees  and  hears  the  God,  or  his  messenger,  who  commands 
him  to  sla}^  himself  or  others.  Often  the  patient  has  a  sort 
of  recognition  of  the  fact  that  the  voices  and  other  sounds 
he  hears  are  not  in  the  outer  world,  and  assigns  their  seat 
to  his  own  head.  One  of  the  writer's  patients  heard  the 
same  melody  indefinitely  repeated  at  a  spot  under  the  left 
parietal  boss.  Others  hear  the  voices  as  if  these  originated 
in  other  parts  of  the  body  ;  if  rhythmical,  in  the  chest;  if 
less  constant  and  regular,  in  the  abdomen.  In  the  former 
case  an  illusional  transformation  of  cardiac  sounds,  and  in 
the  latter  of  intestinal  rumblings  may  be  sometimes  demon- 
strated to  be  the  exciting  cause. 

There  may  be  the  greatest  variety  in  aural  hallucinations; 
they  may  be  limited  for  years  to  the  repetition  of  the  patient's 
name.  A  lunatic  with  this  symptom,  whom  the  writer  ex- 
hibited before  the  New  York  Neurological  Society,  and  who 
heard  his  name  called  by  every  drayman  in  the  street,  after 
assaulting  persons  in  consequence  of  the  imaginary  insults, 
travelled  from  New  York  to  Philadelphia,  and  thence  to  St. 
Louis,  with  the  object  of  getting  rid  of  the  "  persecution." 
Finding  that  the  voices  continued,  he  went  to  Canada, 
thinking  that  in  another  country,  at  least,  he  would  be  let 
alone.  Of  course  the  symptom  continued  and  it  continues 
to  this  day.  The  otherwise  intelligent  patient  had  read 
treatises  on  insanity,  admitted  that  the  writer  was  correct 
in  classing  hallucinations  as  signs  of  insanity,  admitted 
also  that  the  voices  on  the  street  were  not  real,  but  persisted 
in  declaring  that  the  voices  he  heard  at  his  place  of  busi- 
ness were  genuine.  As  the  writer  walked  with  him  to  the 
place  where  the  meeting  of  the  medical  society  was  held, 
he  turned  around  and  said,  "That  driver  called  out  my 
name  now;  you  must  have  been  abstracted  not  to  notice  it." 
A  half  a  year  later  he  sent  a  telegram  requesting  the  writer 
to  come  to  his  place  of  business  and  to  convince  himself,  as 
well  as  to  remedy  the  matter  by  presenting  to  his  persecu- 
tors the  inhumanity  of  calling  out  the  name  of  a  person 
who  was  as  insane  as  he  admitted  himself  to  be.  * 


*  This  case  is  cited  because  it  is  the  purest  example  of  a  single  hallucina- 
tion and  consequent  delusion  continuing  for  a  long  period  (over  ten 
years)  in  the  writer's   experience.      It  aptly  illustrates,  too,  that  the  doc- 


52  INSANITY. 

Hallucinations  of  hearing  are  more  frequently  secondary 
to  delusions  than  hallucinations  of  sight.  This  is  in  har- 
mony with  their  relatively  greater  frequenc)'  in  chronic 
delusional  and  melancholiac  derangement,  of  which  persis- 
tent delusions  or  delusional  states  are  characteristic.  Suf- 
ferers from  hallucinations  of  hearing  under  these  circum-  ' 
stances  are  particularly  dangerous.  They  hear  the  com- 
mand to  kill  some  one,  to  throw  their  children  into  the  fire, 
they  hear  promises  of  eternal  bliss  to  follow  as  a  reward 
of  some  other  terrible  deed,  or  they  hear  themselves  accused 
of  foul  crimes,  or  the  pursuing  footsteps  of  officers  of  the 
law,  and  in  subjective  self-defence  will  kill  or  maim  others; 
or,  to  escape  their  persecutors,  may  resort  to  suicide. 

In  other  cases  the  hallucinations  are  more  agreeable. 
Such  are  generally  more  unfavorable  as  to  prognosis  than 
the  last-mentioned  cases,  although  their  episodial  results 
may  be  less  serious  from  a  medico-legal  point  of  view. 
The  patient  hears  the  "  music  of  the  spheres,"  celestial 
harmonies,  angelic  anthems,  the  tributes  of  his  grateful 
subjects,  or,  like  a  paretic  demented  merchant  from  Chi- 
cago, he  listens  at  the  keyhole  to  the  telegraphic  messages 
of  John  or  Jack,  and  replies,  directing  what  disposal  is  to 
be  made  of  his  extensive  domains,  trunks  of  gold,  and  stock 
investments  in  that  city.  The  conversations  which  pa- 
tients hold  with  imaginary  persons  are,  of  course,  entirely 
the  creation  of  their  own  minds,  and  the  replies  attributed 
to  others  are  nothing  but  the  thoughts  of  the  patient  apper- 
ceived  as  spoken  speech  by  him.*  It  has  even  been  sup- 
posed that  the  mental  processes  of  one  hemisphere  may 
reach  the  degree  of  hallucinations,  while  the  other  func- 
tionates in  a  less  exaggerated  manner,  and  registers  the 
"  hallucinated  thoughts"  as  the  spoken  speech  of  an  imag- 
inary friend  or  enem5\  Support  has  been  supposed  to  be 
derived  in  favor  of  this  theory  from  the  fact  that  hallu- 
cinations of  hearing  are  sometimes  unilateral. 

It  is  an  interesting  observation,  the  analogue  of  which 
was  referred  to   in   speaking  of  visual   hallucinations,  that 

trine  of  a  "partial  punishability"  of  the  so-called  "  partial  lunatics"  is 
an  anachronistic  absurdity.  This  patient  committed  a  series  of  insane 
acts,  more  or  less  directly  based  on  his  hallucinatory  delusion,  several  of 
them  conflicting  with  the  law,  for  all  of  which  he  was,  in  equity,  as  irre- 
sponsible as  the  paretic  who  commits  a  theft  or  an  incendiarism. 

*  The  paretic  dement  in  question  enunciated  both  the  queries  and  re- 
plies himself. 


HALLUCINATIONS   AND   ILLUSIONS.  53 

while  in  earlier  times  the  aural  hallucinations  of  the 
chronic  insane  more  frequently  related  to  celestial  voices, 
the  introduction  of  the  speaking-tube  was  followed  by  a 
transferral  of  the  voices  to  imaginary  systems  of  tubing  in 
the  walls  of  the  patient's  apartment.  Later,  the  introduc- 
tion of  the  telegraph  was  followed  by  the  idea  (heraldic  of 
the  telephone)  that  the  voices  were  carried  to  the  patients 
by  systems  of  wires;  this  delusion  latterly  has  been  modified 
by  the  adoption  of  the  name  of  the  instrument. 

Auditory  illusions  are  generally  based  on  entotic  sounds; 
the  tinnitus  of  cerebral  anaemia*  is  frequently  interpreted 
falsely  by  the  patient.  The  distinguished  comparative 
anatomist,  Leuret,  having  been  bled  on  one  occasion,  com- 
plained of  the  carelessness  of  his  attendants  in  spilling  acid 
on  a  costly  marble  table;  he  hearing,  as  he  claimed,  the 
effervescing  sound  thus  produced.  Moos,  the  Heidelberg 
otologist,  reports  a  case  where  the  bruit \  produced  in  the 
hiilhus  venae  jiigidaris  was  interpreted  by  the  patient  as  the 
noise  of  railroad  trains  and  factories,  to  escape  from  which 
the  patient  committed  suicide. 

Hallucinations  of  smell  and  taste  usually  coexist,  a  fact 
attributable  to  the  close  association  existing  between  our 
conceptions  of  taste  and  smell,  and  an  additional  proof,  if 
it  were  wanting,  that  hallucinations  essentially  originate  in 
the  brain. 

Patients  having  hallucinations  of  sight  or  hearing,  some- 
times have  the  corresponding  hallucination  of  smell  or 
taste.  Thus,  patients  who  in  the  middle  ages  saw  the 
devil,  smelled  his  brimstone;  those  who  hear  conspirators 
suggesting  poisoning,  thereupon  smell  or  taste  poison  in 
their  food.  False  taste  and  smell  perceptions  are  common 
in  hypochondriacal  insanity  and  in  paretic  dementia.  In 
the   latter  disease   they  have  in   the  writer's   experience  a 

*That  extreme  variation  in  any  direction  of  the  bio-chemical  state  may 
produce  disordered  sense  perception  is  illustrated  by  this  case  where 
anaemia  is  the  fundamental  cause,  and  by  the  occasional  observation,  that 
hallucinations  of  hearing  appear  on  assuming  the  horizontal  position  or 
even  on  lying  on  one  side,  that  is,  with  a  relative  hyperaemia. 

f  The  importance  of  this  bruit  in  producing  hallucinations  and  insanity 
has  certainly  been  overestimated  by  Moos.  The  ear  probably  accom- 
modates itself  to  all  vascular  sounds,  in  a  state  of  health;  as  it  must  do 
with  regard  to  the  pulsations  of  the  intrinsic  arteries  of  the  labyrinth; 
just  as  a  miller  after  a  period  ceases  to  hear  the  noise  of  his  mill,  and  dis- 
tinguishes the  lesser  sounds  through  it,  which  are  inaudible  to  the  new- 
comer. 


54  INSANITY. 

bad  import,  and  indicate  rapid  deterioration.  This  ap- 
plies also  to  masturbatory  insanity,  of  which  disorder  such 
hallucinations  are  almost  characteristic.  In  these  three 
forms  of  mental  disorder  the  patients  smell  dead  bodies, 
putrefying  and  filthy  substances,  noisome  gases,  seminal 
discharges,  etc. 

It  is  not  uncommon  to  find  that  alleged  hallucinations  of 
taste  disappear  with  the  relief  of  a  dyspepsia,  showing  that 
in  reality  the  false  sense  perception  is  illusional. 

False  perceptions  of  general  sensor}'  impressions  are 
probably  always  illusional  in  character.  Of  this  kind  was 
the  illusion  of  a  paretic  dement  in  the  writer's  observation 
that  he  was  infested  with  vermin,  of  a  patient  reported  by 
Mickle  whose  skin  was  "  taken  off  and  hung  up  to  dry,"  and 
of  others  who  imagine  their  body  infested  by  maggots,  or 
sprinkled  over  with  gold  coins,  or  turned  to  some  other 
foreign — generally  valuable — substance.  The  degenerative 
changes  in  the  spinal  cord  noted  in  such  cases  furnish  the 
basis  for  the  false  perception.  Hypochondriacal  and  hys- 
terical lunatics  find  a  rich  field  for  false  beliefs  in  illusions 
of  touch  and  of  the  visceral  sensations.  The  demonoma- 
niac  interprets  borborygmi,  pulsations  in  the  head,  inter- 
missions of  the  heart  beat,  and  heaviness  at  the  pit  of  the 
stomach,  as  the  assaults  of  the  demons  within.  The  delu- 
sional lunatic  with  a  hypochondriacal  tendency  believes 
that  his  limbs  are  made  of  glass,  stone,  wood,  or  cork. 
The  hysterical  delusionist  imagines  that  she  feels  the  move- 
ments of  a  child  or  an  animal,  on  the  strength  of  her  tym- 
panitic distension  and  intestinal  movements. 

Even  here,  the  influence  of  the  age  is  felt,  and  those  dis- 
ordered perceptions  which  were  interpreted  as  the  result 
of  supernatural  influences  in  the  middle  ages  are  to-day 
described  as  electrical  sensations,  ascribed  to  magnetic  and 
planetary  influences,  or  attributed  to  the  intrigues  of  se- 
cret societies. 


CHAPTER  V. 

The  Emotional  Disturbances. 

Disturbances  of  the  emotional  state  are  almost  univer- 
sal   in   insanity.       With    the   exception    of    the   congenital 


THE   EMOTIONAL   DISTURBANCES.  55 

forms  of  derangement  and  those  dating  from  childhood, 
all  insanities  exhibit  as  an  initial  feature  a  change  in  the 
emotions.  Either  these  are  more  readily  aroused  than  in 
health,  as  in  the  pathological  fury  *  which  is  manifested  by 
patients  suffering  from  head  injuries,  epilepsy,  and  neural- 
gia, and  particularly  in  the  prodromal  period  of  paretic  de- 
mentia; or  they  are  less  easily  aroused:  the  emotions  are 
blunted,  as  in  stupor,  in  the  emotional  indifference  to 
friends  and  relatives  of  the  melancholiac,  in  the  last  stages 
of  paretic  dementia,  in  the  terminal  deteriorations,  and, 
above  all,  in  alcoholic  and  epileptic  insanity. 

There  are  two  forms  of  emotional  disturbance  which  are 
pathognomic  of  the  antithetical  groups:  mania  and  melan- 
cholia; and  which,  constituting  as  they  do  their  intrinsic 
features,  will  be  discussed  together  with  these. 

Great  confusion  has  arisen  from  the  use  of  the  term 
EMOTIONAL  INSANITY.  If  this  term  were  to  be  limited  to 
those  forms  of  derangement  in  which  the  perversion  of  the 
emotions,  in  the  strictest  sense,  is  the  essential  and  unvary- 
ing feature,  it  would  be  a  useful  designation  for  that  gen- 
eral class  of  simple  insanities  comprising  mania  and  mel- 
ancholia. But,  unfortunately,  it  has  been  applied  in  the 
very  widest  sense,  and  stretched  to  cover  the  conception  of 
moral  disturbance  as  well. 

There  are  several  psychological  as  well  as  psychiatrical 
reasons  for  separating  the  senfitnefits  from  the  emotions.  It 
may  suffice  to  point  to  the  fact  that  there  are  many  pa- 
tients in  whom  there  is  a  painful  emotional  state  who  do 
not  become  less  benevolent  or  less  kindly  disposed,  though 
perhaps  more  indifferent  to  the  world  at  large  or  their  re- 
latives, just  as  there  are  patients  developing  an  expansive 
emotional  state  who  do  not  entertain  more  elevated  senti- 
ments than  they  did  before,  and  often,  indeed,  become 
more  profane,  vulgar,  and  cruel,  presenting  a  great  moral 
contrast  with  their  emotional  exaltation.     The  moral  sen- 


*" Affect"  of  the  Germans;  this  condition  has  been  frequently  con- 
founded with  "  transitory  mania  s.  furor"  from  which  it  differs  in  the 
fact  that  while  the  memory  for  the  acme  of  the  former  state  may  be 
abolished,  it  is  not  destroyed  for  the  whole  period  of  the  disturbance  as 
in  transitory  furor.  In  our  forensic  annals  many  cases  of  pathological 
(and  non-pathological)  fury  may  be  found,  where  the  plea  of  emotional 
insanity,  transitory  mania,  moral  insanity,  homicidal  mania,  or  epilepsy, 
has  been  made,  with  the  result  of  confusing  the  criminal  jurisconsulist 
and  throwing  discredit  on  forensic  psychiatry. 


56  INSANITY. 

timents  may  be  unaffected  while  the  emotional  ones  are 
disordered,  and  vice  versa.  While  there  is  a  bond  of  con- 
nection between  them,  it  is  in  the  alienist's  experience  not 
an  absolute  one. 

Disorder  of  the  moral  sentiments  may  be  congenital,  and 
equivalent  to  a  partial  imbecility,  as  the  father  of  Ameri- 
can mental  science.  Rush,  first  pointed  out.  The  memory 
and  the  reasoning  powers  may  be  so  slightly  affected  in 
this  condition  that  their  deficiency  is  practically  unno- 
ticeable;  or  the  reasoning  processes — and  this  is  more  fre- 
quent— may  be  as  perverse  as  the  moral  state.  Moral 
perversion  may  be  also  acquired.  It  is  a  common  accom- 
paniment of  advanced  epileptic,  and  it  is  constant  in  mas- 
turbatory  insanity.  In  paretic  dementia  and  other  terminal 
states  it  is  also  observed,  but  its  mechanism  is  here  some- 
what peculiar,  and  the  moral  perversions  of  the  deteriorat- 
ing forms  require  a  separate  consideration.  (See  Part  II.) 
In  traumatic  and  alcoholic  insanity,  moral  perversion,  or  a 
blunting  of  the  moral  sentiments,  seems  to  grow  out  of  the 
corresponding  emotional  obtuseness. 

It  may  be  advanced  as  a  cardinal  canon  of  psychiatry  that 
in  insanity  the  moral  feelings  are  usually  more  or  less  dulled 
or  perverted.*  The  deficiency  of  the  moral  feelings  may, 
however,  be  of  a  different  kind;  in  certain  cases  it  may  be 
a  necessary  result  of  intellectual  enfeeblement,  it  may  be  due 
to  an  obtuse  emotional  condition,  or  it  may  be  an  original 
deficiency  analogous  to  that  lack  of  musical  sense,  or  color- 
blindness, which  may  coexist  with  a  fair  faculty  of  lan- 
guage and  good  contour  perception,  just  as  that  moral 
imbecility  which  authors  call  moral  insanity  may  be  found 
associated  with  fairly  good  logical  powers  in  the  abstract. 
An  intense  egotism  is  sometimes  found  to  lie  at  the  root  of 
a  constitutional  inability  of  the  individual  to  recognize  any 
moral  obligation  to  others.  In  such  cases,  abstract  moral 
conceptions  may  be  inculcated  by  education.  But  the  sub- 
ject of  this  condition,  while  he  may  be  able  to  guide  his 
conduct  by  these,  regards  them  as  purely  utilitarian  con- 

*  Is  it  necessary  to  add  that  insanity  does  not  increase  or  develop  the 
moral  sentiments  ?  It  seems  so.  The  fact  that  a  noted  insane  criminal 
whose  crime  and  trial  agitated  the  whole  country  a  few  months  ago  had 
had  venereal  disease,  had  committed  adultery  for  the  purpose  of  procur- 
ing a  divorce,  had  entered  the  Oneida  Community,  and  owed  numerous 
debts  for  board  and  lodging,  induced  a  large  number  of  medical  witnesses 
to  pronounce  him  sane  ! 


MEMORY   AND    CONSCIOUSNESS   IN   INSANITY.         57 

ceptions.  They  never  become  as  organically  fixed  as  where 
they  have  been  developed  from  that  inborn  tendency  which 
is  the  common  heritage  of  normal  mankind. 


CHAPTER  VI. 

The   Memory  and    Consciousness   in   Insanity. 

Disturbances  of  the  memory  are  common  among  the 
insane,  either  as  temporary  symptoms  of  the  acute  and 
transitory  forms  of  insanity  and  the  exacerbations  of  the 
chronic  forms,  or  as  progressive  and  permanent  accompani- 
ments of  terminal  deterioration. 

Amnesia,  or  loss  of  memory,  is  characteristic  of  the  epi- 
leptic mental  states,  where,  while  the  memory  for  all  impres- 
sions prior  to  the  explosion,  as  well  as  subsequent  to  it, 
may  be  unimpaired,  the  recollection  of  the  events  transpir- 
ing during  the  attack  is  either  obliterated  or  clouded.  It 
is  found  in  degrees  varying  with  the  intensity  of  the  intoxi- 
cation in  alcoholic  and  othernarcotic  insanities.  It  is  more 
or  less  marked  in  the  delirious  phases  of  mania,  melan- 
cholia, and  the  hysterical,  parturient,  and  febrile  states. 
Finally,  it  is  a  most  important  feature  of  paretic  demen- 
tia and  other  forms  of  insanity  with  organic  disease  of 
the  brain. 

While  the  condition  of  the  memory  in  the  various  forms 
of  insanity  can  be  more  appropriately  discussed  in  the  sec- 
ond part  of  this  volume,  it  is  desirable  to  lay  stress  on  two 
prominent  facts  at  the  outset. 

In  the  first  place,  the  current  idea  that  all  forms  of 
insanity  are  accompanied  by  loss  of  memory  is  a  false  one; 
so  false  that  the  pretence  of  having  lost  the  memory  is 
under  certain  circumstances  justly  considered  the  strongest 
evidence  of  simulation.  Quite  aside  from  those  sub-acute 
maniacal  cases  in  which  the  memory  appears  to  be  morbidly 
sharpened  for  the  time  being,  there  are  a  large  number  of 
mild  melancholiacs  in  whom  the  memory  does  not  appre- 
ciably suffer.  But,  above  all,  there  is  a  larger  class  of  the 
chronic  insane  in  whom  for  many  years,  and  often  through 
a  long   life,  the   memory  remains  as  good  as  that  of   the 


58  INSANITY. 

average  human  being,  and  may  even  be  noted  for  its  faith- 
fulness in  regard  to  details.     (See  Monomania.) 

Secondly,  it  is  erroneous  to  infer  that  because  a  series  of 
acts  is  carried  out  by  a  subject  with  an  appearance  of 
method  and  purpose,  that  these  acts,  their  object  and  re- 
sults, must  necessarily  remain  registered  in  the  memory. 
There  are  many  automatic  and  even  higher  acts  performed 
by  epileptics  in  the  post-epileptic  state;  but  the  entire 
period  during  which  those  acts  are  performed,  may  become 
an  absolute  blank  in  his  mind  when  it  returns  to  lucidit}^ 
In  the  case  of  a  policeman,  whose  interesting  histor}^  is  de- 
tailed in  the  chapter  on  Epileptic  Insanity,  the  patient  went 
out  imperfectly  dressed,  but  doffed  his  badge,  seized  his 
club,  and  patrolled  a  "  beat" — the  wrong  one,  it  is  true, 
but  still  he  patrolled  it  in  such  a  way  as  to  attract  no 
special  notice.  However,  he  knew  nothing  of  it  after- 
ward. 

Proof  that  still  higher  mental  combinations  and  projects 
may  be  formed  and  executed,  even  in  sanity,  which  after- 
ward escape  the  memor}'  altogether,  is  furnished  by  some 
of  the  rarer  phenomena  of  somnambulism.  Condorcet, 
the  mathematician,  solved  a  mathematical  problem,  which 
had  worried  him  the  day  previous,  during  a  somnambulis- 
tic state,  and  had  no  recollection  of  tlie  fact  the  following 
morning.     Similar  observations  are  made  on  the  insane. 

Sometimes  an  entire  period  of  life  during  which  a  patient 
has  been  insane  appears  blotted  out  of  his  memory,  and  in 
convalescing  he  may  consequently  consider  himself  to  be 
still  of  the  same  age  as  when  the  disease  began.  But  in 
most  cases  individuals  recovering  from  insanity  recollect 
what  had  occurred  during  their  illness;  and  our  juries  have 
not  unfrequenth'  been  moved  to  pronounce  an  unquestion- 
able lunatic,  claiming  his  discharge  from  an  asylum  on  the 
ground  of  self-alleged  sanity,  a  sane  man,  because  of  the 
detailed,  circumstantial  and  connected  account  which  the 
patient  was  able  to  give  of  the  events  leading  to  his  com- 
mitment, and  of  those  transpiring  during  an  asylum  so- 
journ extending  over  many  months  or  years.  This  faith- 
fulness of  the  memory  is  found  in  the  milder  cases  of  acute 
insanity  and  in  monomania.*    In  more  severe  grades  of  acute 

*Griesinger,  confounding  chronic  mania  with  confusion  of  ideas  or 
chronic  secondary  insanity  with  monomania,  makes  the  misleading 
statement  that  the  memory  is  confused  in  monomania. 


MEMORY   AND   CONSCIOUSNESS   IN   INSANITY.         59 

insanity,  and  even  in  some  of  the  epileptic  and  particularly 
the  toxic  psychoses,  the  patient  retains  what  the  Germans 
term  '■'■  Summarische  Erinnening,'"  that  is,  a  faint,  sketch-like 
recollection  of  the  main  events  occurring  during  the  attack. 
Often  the  memory  for  past  events  is  unimpaired,  but  the 
patient  finds  it  difficult  to  reproduce  his  recollections,  owing 
to  a  temporary  depression  of  the  associating  apparatus. 
This  is  particularly  common  in  melancholia.  With  such  a 
condition  the  reception  of  new  impressions  is  impaired, 
but  it  must  be  always  borne  in  mind  that  the  common  state- 
ments of  patients  convalescing  from  an  acute  insanity,  that 
they  have  no  recollection  of  their  insane  period,  must,  with 
certain  exceptions,  be  discredited,  as  these  patients  feel 
humiliated  by  their  recollections,  and  waive  every  reminder 
by  the  easily-made  claim  of  total  amnesia. 

A  very  curious  disturbance  of  the  memory  is  manifested 
in  the  condition  known  as  double  or  altei-natiitg  consciousness. 
It  is  exceedingly  rare,  and  appears  to  be  limited  to  the 
mental  disturbances  of  menstruation  and  to  periodical  in- 
sanity. 

This  condition  is  characterized  by  the  alternation  of 
periods,  in  which  the  subject  enjoys  his  memory  and  retains 
his  sense  of  identity,  with  others,  in  which  he  fails  to  recol- 
lect the  impressions  of  his  healthy  period,  but  possesses 
the  faculty  of  learning  new  ones.  In  the  next  healthy 
period  he  recollects  what  occurred  before  the  abnormal 
period,  but  does  not  reproduce  every  fact  acquired  in  the 
latter.  ■  In  short,  the  mental  life  of  two  distinct  individuals 
seems  to  alternate  in  one  person.* 

It  is  the  multitude  of  impressions  and  experiences  regis- 
tered in  the  organ  of  the  memory  that  constitute  the  con- 
scious ego.  Healthy  consciousness  is  that  condition  in  which 
the  individual,  while  registering  the  impressions  of  the  outer 
ivorld  to  ivhich  his  attention  is  directed  at  the  time,  correlates  these 

*  Some  remarkable  instances  may  be  found  related  in  Forbes  Winslow's 
treatise  on  "Obscure  Diseases  of  the  Brain  and  Mind."  It  is  a 
noteworthy  circumstance  that  few  of  these  are  verified  by  more  than  one 
observer,  and  that  few  or  none  have  been  reported  within  more  recent 
times.  In  one  case,  a  girl  who  was  outraged  in  the  morbid  period 
revealed  this  fact  in  the  next  morbid  period,  but  had  no  recollection  of  it 
in  the  intervals.  The  occasional  observation  that  epileptic  patients  whose 
attacks,  manifesting  themselves  in  automatic  acts  or  in  rhyming 
deliria,  are  repeated  in  the  same  way,  as  in  a  case  reported  by  the  writer 
in  the  Medical  Record  for  1881,  presents  some  analogies  to  double  con- 
sciousness. 


6o  INSANITY. 

with  the  summarized  obsn-vations  of  the  past.  The  sum  of  tbe 
observations  constituting  the  ego  is  continually  increasing; 
the  scope  of  the  ego  becomes  wider  with  ever}''  added  im- 
pression, every  correction  of  a  perceptional  or  conceptional 
error,  and  with  every  new  experience.  The  ego  of  the  child 
is  a  different  one  from  that  of  the  adult;  but  it  is  the 
nucleus  around  which  the  ego  of  the  adult  is  to  gather.  In 
other  words,  the  ego  of  an  individual  is  throughout  the 
same  complex  unit,  composed  of  the  correlated  and  asso- 
ciated notional  items  collected  up  to  a  given  time;  but  it  is 
variable  to  this  extent,  that  it  is  continually  forming  new 
bonds  and  adding  new  notional  items  to  its  mechanism  in 
a  healthy  state.  Consciousness  is  merely  a  single  designa- 
tion for  that  state  in  which  this  addition  is  being  made.  It 
involves,  in  the  first  place,  the  healthy  memory  of  the  past, 
that  is,  not  a  detailed  memory  of  the  entire  past  at  the 
given  moment,  but  that  summarized  sense  of  identity — the 
(f^''<?-consciousness  which  is  as  it  were  an  abstract  of  the 
chief  memories  of  the  entire  past  ;  and  secondly,  the 
functional  disposition  to  add  to  these  memories  and  to  in- 
corporate them  with  the  continuous  ego. 

So  complex  a  mechanism  as  the  ego,  is,  corresponding  to 
its  complexity,  readily  deranged,  and  it  is  its  disturbance 
in  insanity  that  constitutes  the  most  essential  feature  of 
that  disorder,  the  one  whose  analysis  from  a  medical  point 
of  view  is  most  important,  and  the  one  without  which  no 
medico-legal  stud}' of  insanity  can  be  reasonably  attempted. 

Self-consciousness  may  be  disturbed  in  any  one  of  its 
factors.  It  is  alwa}'S  materially  influenced  by  disturbances 
of  the  memory;  and  no  grave  disorder  of  the  memory  is 
supposable  without  a  corresponding  disturbance  of  the 
ego,  for  it  deprives  the  latter  of  important  component  ele- 
ments. But  the  intrinsically  important  disturbances  of  the 
ego-consciousness  are  of  a  different  nature:  they  relate  to 
the  failure  or  the  functional  indisposition  of  the  ego  to  in- 
corporate the  changing  outer  impressions,  and  to  accom- 
modate itself  to  them,  or  its  inability  to  properly  correlate 
these  impressions  with  those  already  accumulated. 

Change  of  the  sense  of  identity  is  a  result  of  the  lat- 
ter disability.  The  individual  registering  the  impressions 
and  conceptions  of  a  given  period  of  life,  and  combining 
them  in  a  distinct  union,  without  uniting  them  to  those  of 
the  past,  there  result  two  egos,  a  present  and  a  past  one. 
Lunatics  exhibiting  this  plienomenon  may  recognize  in  a 


MEMORY   AND   CONSCIOUSNESS   IN   INSANITY.        6l 

shadowy  way  the  conflict  between  the  old  ego  and  the 
spurious  one;  they  then  complain  that  they  have  been 
changed,  and  have  become  other  individuals,  in  which  case 
they  will  often  speak  of  their  former  selves  in  the  third 
person.  More  frequently  the  patient's  spurious  ego  over- 
whelms the  ego  of  the  past,  a  complete  change  in  senti- 
ments and  conceptions  occurs,  and  a  person  previously  a 
prosperous  mechanic  may  so  identify  himself  with  the 
false  character  construed  on  a  delusional  basis,  that  it  re- 
mains his  supposed  nature  for  life;  he  continues  to  his 
death  to  believe  himself  a  king,  a  religious  reformer,  or  a 
cheated  inventor. 

It  has  been  occasionally  observed  where  the  patient  has 
a  divided  identity  that  the  conceptions  of  either  the  normal 
ego  or  the  spurious  one  rise  to  the  surface  in  the  shape  of 
hallucinations,  and  under  these  circumstances  asylum  in- 
mates can  occasionally  be  found  sustaining  dialogues  be- 
tween their  older  and  their  newer  and  morbid  selves. 

Sometimes  the  insane  lose  all  sense  of  time,  place,  prop- 
erty, and  propriety  for  a  short  period,  to  regain  it  again. 
This  is  particularly  noticeable  in  senile  and  paretic  de- 
mentia, in  which  disorders  the  patients  may,  even  before 
serious  illness  is  suspected,  lose  their  way  in  the  streets,  go 
out  without  being  properly  dressed,  leave  restaurants  with- 
out paying  for  their  meals,  post  letters  without  any  direc- 
tions, sign  documents  or  draw  checks  without  method, 
.and  do  a  hundred  other  things  which  are  like  to  those  done 
by  healthy  persons  in  fits  of  abstraction;  but  they  differ 
from  them  in  this,  that  there  is  a  real,  substantial  loss  of 
consciousness,  not  a  temporary  blurring  by  an  overwhelm- 
ing but  intense  healthy  mental  process. 

One  of  the  most  important  states  of  consciousness  in  the 
insane  is  that  which  many  melancholiacs  and  paretics 
manifest  early  in  their  disorder,  namely:  the  conscious- 
ness of  an  impending  loss  or  disturbance  of  reason.  It  is 
probably  less  the  result  of  a  true  appreciation  of  the  sub- 
jective mental  phenomena  than  the  direct  result  of  strange 
intracranial  or  perhaps  of  visceral  sensations,  due  to  the  nu- 
tritive or  destructive  lesion  of  the  brain.  In  other  forms  of 
insanity  the  appreciation  by  the  patient  of  his  morbid  state 
as  a  morbid  one  is  the  best  augury  of  a  happy  termination 
of  his  illness.* 

*The  various  forms  of  disturbance  of  consciousness,   such  as  stupor, 


62  INSANITY. 

It  is  a  noteworthy  fact  that  patients  who  liave  entirely  lost 
their  normal  self-consciousness,  and  whose  mental  mechan- 
ism has  been  used  to  construct  a  false  and  absurd  identity, 
are  yet  able  to  appreciate  their  objective  surroundings  in 
their  real  characters,  while  utterly  unable  to  regulate  their 
subjective  beliefs  b)''  them.  Thus  a  paretic  dement  with 
the  most  extravagant  delusions  looked  down  with  con- 
tempt on  another  patient  suffering  from  a  mental  obtuse- 
ness  following  cerebral  hemorrhage  as  a  "  poor,  paralyzed 
fool,"  and  the  writer  has  not  unfrequently  witnessed  the 
badinage  which  patients  indulged  in  against  their  fellows 
on  a  basis  of  mental  infirmities  actually  observable  in  the 
latter.  The  case  related  by  Zacchias,  observed  in  a  Roman 
asylum,  can  probably  be  duplicated  in  every  larger  institu- 
tion for  the  insane.  A  visitor  entering  the  one  in  question 
was  shown  around  by  a  ver}^  intelligent  cicerone,  who  ex- 
plained the  nature  of  each  patient's  insanity,  drew  out 
delusions,  and  otherwise  made  the  visit  of  the  stranger 
so  interesting  and  profitable,  that  the  latter  thought  him 
to  be  one  of  the  asylum  authorities,  if  not  the  superin- 
tendent himself.  Finally  they  came  to  a  little  chamber, 
where  the ''cicerone"  said  (pointing  out  a  patient),  "Here 
is  a  sad  case — the  worst  one  in  the  asylum.  This  poor  fellow 
thinks  he  is  the  Redeemer  of  mankind — the  fool,  when  it  is 
I  who  am  the  true  Redeemer!" 

The  insane  are  not  blind  to  the  merits  and  demerits  of 
the  sane  either;  a  fact  important  to  bear  in  mind  in  their 
treatment.  In  more  than  one  instance  has  the  writer  known 
the  patients  of  an  asylum  to  expose  the  ignorance  of  per- 
sons in  authority  with  a  sarcasm  and  wit  which  was  far 
from  unjustified  by  the  facts  of  the  case.  A  paretic 
dement,  whose  disorder  was  a  complication  of  a  pre-ex- 
isting monomania,  and  who  had  earlier  in  his  career  been  a 
proficient  surgeon  and  dentist,  successfully  defied  a  col- 
league to  enumerate  the  cranial  nerves  or  their  foramina 
of  exit;  burst  out  in  a  torrent  of  invective  against  such  ig- 
norance, and,  without  a  penn\^  in  his  pocket,  announced  the 
project  to  build  a  large  school  adjoining  the  as3'lum  in 
which  to  instruct  physicians  in  the  rudiments  of  medicine 


ecstasy,  and  those  associated  with  delirium  and  epileptic  states,  are  dis- 
cussed in  the  second  part  of  the  book.  The  same  disposition  has  been 
made  of  certain  special  disturbances  of  the  will,  and  other  signs  which 
would  otherwise  require  repeated  discussion. 


MEMORY   AND    CONSCIOUSNESS    IN   INSANITY.        63 

and  the  anatomy  and  physiology  of  the  brain,  "according 
to  Bell  and  Magendie."  A  female  monomaniac,  who  had 
escaped  or  been  "  liberated  "  from  several  asylums,  ridiculed 
the  faulty  logic  and  ignorance  of  an  asylum  officer  who  was 
an  advocate  of  phrenology,  and  who  actually  claimed  in  one 
of  his  annual  reports  that  his  great  success  in  the  treatment 
of  the  insane  was  due  to  his  phrenological  attainments. 
Shortly  after  the  testimony  of  the  medical  witnesses  for 
the  prosecution  in  the  Guiteau  trial  was  given — an  impor- 
tant feature  of  which  was  the  unanimous  statement  by  these 
gentlemen  that  insanity  was  never  hereditary — the  male 
patients  in  one  ward  of  a  large  State  asylum,  whose  super- 
intendent had  testified  in  addition,  "disease  is  never  trans- 
mitted," held  a  meeting  and  passed  certain  resolutions 
relating  to  the  superintendent — grounding  them  on  the 
fact,  that  almost  the  first  questions  asked  of  a  patient's 
relatives  on  his  arrival  at  that  same  asylum,  related  to  the 
hereditary  history.  When  the  writer  adds  that  the  mem- 
ber of  this  "convention"  who  reported  the  incident  to  him 
was  a  patient  who  had  claimed  and  obtained  his  liberty  by 
legal  methods,  and  who  was  undoubtedly  insane  still,  also 
admitted  that  his  fellow  patients  who  had  been  "liberated  " 
in  the  course  of  a  liberation  epidemic  were  still  insane — 
which  was  true,  though  sane  juries  and  judges  saw  it  not — 
and  that  he  himself  suffered  from  an  organic  affection  of  the 
brain  which  had  affected  his  mind — which  was  also  true — 
the  reader  may  form  some  idea  of  the  erroneous  nature  of 
the  views  on  the  strength  of  which  physicians  unfamiliar 
with  the  insane  pass  on  the  question  of  mental  ,soundness, 
believing  that  a  lunatic  must  be  a  lunatic  to  his  fingers' 
ends,  and  must  be  at  all  points  and  at  all  times  unreason- 
able in  his  thoughts  and  absurd  or  extravagant  in  his  acts. 
The  mind  of  an  insane  person  may  be,  and  in  some  in- 
stances is,  a  more  elaborate  mechanism,  one  with  more  in- 
dividual components,  and  of  consequent  wider  scope  as  to 
its  combinations,  than  the  mind  of  many  a  sane  person.  But 
the  mental  factors  of  a  healthy,  inferior  mind,  if  fewer  in 
number  and  simpler  in  their  associations,  are  well  arranged 
and  united  into  a  consistent  and  continuous  ^a""^.  It  is  the 
failure  to  effect  this  union  that  constitutes  the  chief  element 
of  what  is  so  aptly  called  dc ra iige )/ie nt  a.nd  alienation. 


64  INSANITY. 

CHAPTER  VII. 

The  Will  in  Insanity. 

There  is  probably  not  a  single  case  of  insanity  in  which 
the  will  in  the  widest  sense  is  not  at  some  time  or  other  in 
the  course  of  the  illness  more  or  less  disturbed.  The  free 
determination  of  the  will  in  certain  directions  is  perverted 
by  delusions;  it  is  hampered  by  delusive  interpretations  and 
by  depressive  emotional  states;  finally,  it  is  disturbed  by 
delirium,  confused  by  incoherence,  and  abolished  by  de- 
mentia. The  patient  who,  apparently  of  sound  mind  to  the 
laity,  in  other  directions,  believes  that  if  he  looks  out  of  a 
window  he  will  poison  the  world  with  a  glance,  and  ccnse- 
quentl}?^  persists  in  staring  at  a  wall  or  in  keeping  his  eyes 
closed,  has  his  will  perverted  by  the  delusion.  But  in  all 
these  and  similar  cases  the  will  is  not  intrinsically  deranged, 
but  misapplied.  As  far  as  its  strength  is  concerned,  and 
irrespective  of  its  delusive  basis,  the  will  of  an  inspired  or 
calculating  lunatic  is  analogous  to  that  of  a  fanatic  or  a  de- 
termined adventurer:  it  may  indeed  be  remarkable  for  its 
firmness,  but  for  firmness  in  a  direction  which  is  determined 
by  disease. 

It  is  thus  often  seen  that,  as  far  as  the  deliberate  planning 
and  execution  of  an  insane  act  is  concerned,  it  differs  in  no 
wise  from  tlie  acts  requiring  planning  and  deliberation  in 
the  sane.  Yet  the  original  motive  may  be  the  most  extrav- 
agant delusion  or  project,  the  most  disgusting  morbid  pro- 
pensity, or  the  most  horrible  imperative  impulse. 

In  those  forms  of  insanity  in  which  the  ego  is  exalted 
there  is  a  corresponding  exaltation  of  purpose.  The  maniac, 
thinking  himself  to  be  physically  and  mentally  powerful, 
becomes  as  extravagant  in  his  undertakings  as  he  is  in  his 
self-esteem  and  his  word-delirium.  In  other  words,  he 
becomes  hyperbulic.  But,  owing  to  the  multitude  of  concep- 
tions crowding  on  him,  and  the  corresponding  multiplicity 
of  purposes,  some  of  which  may  even  conflict  with  each 
other,  the  projects  and  their  execution  in  the  maniac  and 
maniacal  paretic  appear  to  be  unsystematized  and  boyish. 

In  insanity  with  depression,  the  opposite  condition  of 
affairs,  or  abulia,  is  found.  Here  the  patient  is  unable  to 
exert  his  will,  either  on  account  of  the  arrested  and  impeded 
ideation,  or  because  everything  appears  blank  and  hopeless 


PHYSICAL   INDICATIONS   OF   ACQUIRED    INSANITY.   65 

to  the  patient.  In  melancholia,  however,  of  that  form  in 
which  physical  depression  is  least  marked  and  in  which  de- 
lusions are  absent,  the  most  appalling  forms  of  combined 
suicide  and  homicide,  revealing  a  most  determined  if  a 
morbidly  based  will,  are  common  occurrences. 

The  inability  of  certain  patients  to  rid  themselves  of  ab- 
surd thoughts,  of  aberrant  trains  of  ideas — Griibclsucht — 
and  of  morbid  fears — Mysophobia,  Agoraphobia — is  the  ex- 
pression of  a  disturbance  of  that  higher  phase  of  the  will 
by  which  the  healthy  human  being  is  able  to  limit  his  at- 
tention to  the  real,  or  to  let  it  travel  off  in  the  realms  of 
fancy  as  his  choice  may  direct.  In  the  insane  with  impera- 
tive conceptions  this  choice  is  rendered  less  free  or  impossi- 
ble by  the  dominant  idea. 

The  French  have  given  the  name  manie  or  folic  raissonante 
to  a  form  of  insanity  in  which  the  reasoning  powers  in  the 
abstract  suffer  little  or  not  at  all,  while  the  will  is  greatly 
disordered.  Under  this  unfortunate  term  a  chronic  dis- 
order properly  classed  under  monomania,  as  well  as  the 
lighter  form  of  acute  mania,  have  been  confounded.  It  is 
observed  that  such  patients  can  reason  plausibly,  speak  in- 
telligently, but  commit  absurd  acts,  whose  absurdity  they 
may  recognize  and  apologize  for  afterwards.  These  sub- 
jects may  even  be  noticeable  for  their  keen  wit,  apparent 
shrewdness,  and  the  skill  with  which  they  seek  to  conceal 
or  to  palliate  their  acts.  But,  in  studying  the  career  of  such 
individuals  as  a  whole,  it  is  discovered  that  their  whole  life 
history  consists  of  a  series  of  such  absurd  and  insane  acts; 
and  a  closer  analysis  shows  that  where  these  are  not  the 
outcome  of  imperative  conceptions  and  morbid  propensi- 
ties, they  are  based  on  a  reasoning  which,  however  super- 
ficially bright  and  to  that  extent  misleading  to  the  laity,  is 
as  faulty  logically  as  the  acts  which  it  provokes. 


CHAPTER  VIII. 

The  Physical  Indications  of  Acquired  Insanity. 

The  great  central  organ  whose  disordered  states  are  some- 
times manifested  in  mental  alienation  is  not  only  the  mirror 
of  the  outer  world,  as  Wundt  aptly  expresses  it,  but  in  its 
ganglionic   masses   and   expansions  it  receives   fibres  con- 


66  INSANITY. 

nected  with  every  visceral  and  other  somatic  periphery,  and 
consequently  reflects  and  influences  the  activities  of  the 
body  itself.  The  impressions  which  are  utilized  in  the 
building  up  of  conceptions,  the  motor  innervations  which 
in  their  intricate  association  mediate  the  expression  of  the 
will  and  of  symbolized  thought,  and  the  visceral  and  vaso- 
motor innervations  which  stand  in  such  intimate  relations 
to  the  emotional  states,  are  all  projected  in  the  organ  whose 
diffuse  disease  processes  may  determine  mental  alienation. 
It  is  not  surprising,  then,  that  functions  mediated  through 
the  same  organ  should  in  its  diseases  be  disturbed  together; 
in  other  words,  that  physical  indications  should  mark  the 
development  of  mental  disorder. 

The  special  interest  which  attaches  to  the  physical  indi- 
cations of  insanity  is  twofold.  In  the  first  place,  as  they 
are  more  tangible  to  our  instruments  of  precision  than  the 
mental  signs,  they  are  of  great  value  in  indicating  the 
nature  of  the  presumable  physical  disorder  underlying  in- 
sanity, in  the  frequent  absence  of  positive  post-mortem  evi- 
dence. In  the  second  place,  the  ph3'sical  signs  constitute, 
when  well  marked — as  they  are  in  certain  forms  of  insanity 
— such  unfailing  criteria  of  those  forms,  that  they  are  not 
only  of  great  aid  in  the  diagnosis  of  these  affections,  but 
also  of  efficient  service  in  the  detection  of  simulation. 

The  physical  signs  of  insanity  naturally  fall  into  two 
groups:  first,  tliose  which  are  initial  or  accompanying  phe- 
nomena of  an  insanit}'  affecting  previously  healthy  individ- 
uals; second,  those  which  are  indications  of  a  transmitted 
or  acquired  constitutional  taint;  in  other  words,  signs  of  a 
predisposition  to  insanity.  These  will  be  considered  sepa- 
rately. 

The  condition  of  the  retina  in  insanity  has  been  ex- 
tensively studied,  and  the  introduction  of  the  ophthalmo- 
scope was  followed  by  the  most  extravagant  claims  with 
regard  to  its  importance  in  the  diagnosis  of  insanity.  It  is 
generally  recognized  that  this  instrument  is  of  great  value 
in  diagnosticating  other  cerebro-spinal  affections,  such  as 
posterior  spinal  and  diffuse  sclerosis,  tuberculosis  of  the 
pia,  and  tumors  of  the  brain.  It  is  an  invaluable  adjunct 
in  determining  the  existence  of  those  phases  of  kidney  dis- 
ease which  are  most  likely  to  be  associated  with  mental 
troubles,  and  it  should  always  be  employed  in  suspected 
paretic  dementia,  syphilitic  and  other  forms  of  insanity 
with  organic  disease,  because  these  may  be  accompanied  by 


PHYSICAL   INDICATIONS    OF  ACQUIRED    INSANITY.   6/ 

changes  in  the  ocular  background  hinting  at  if  not  demon- 
strating the  nature  of  the  disorder.     (See  Paretic  Dementia.) 

Aside  from  insanity  with  organic  diseases,  the  psychoses 
do  not  manifest  such  regularity  in  the  retinal  condition  as 
to  justify  the  loudly-trumpeted  claim  of  Bouchut,  that  the 
ophthalmoscope  is  also  a  "cerebroscope,"  nor  the  fanciful 
and  bold  assertions  of  those  who  have  actually  attempted  to 
exalt  this  instrument  to  the  position  of  a  medico-legal  test 
of  insanity!  In  maniaciil  and  delirious  conditions  generally, 
there  may  be  a  hyperaemic  flush  of  the  optic  disk,  and  in  stu- 
por and  passive  melancholia  this  region  may  be  very  anaemic. 
But  these  deviations  from  the  ideal  healthy  state  are  not 
more  considerable  than  those  encountered  in  any  large  eye- 
clinic  whose  material  is  derived  from  a  sane  population. 
The  writer  has  observed  an  extreme  hyperaemia  of  the  disk 
in  three  cases:  one  that  of  an  acutely  delirious  maniac,  who 
died  of  maniacal  exhaustion,  and  whose  brain  exhibited 
commencing  organic  changes;  the  second,  that  of  a  paretic 
dement,  the  inception  of  whose  disorder  was  marked  by 
overwhelming  hallucinations  of  fiery  visions,  and  whose  ill- 
ness ran  a  furibund  and  rapid  course;  the  deep  flush  found 
in  the  latter  case  was  exceeded  in  a  sufferer  from  a  saturnine 
encephalopathy  with  mental  derangem.ent  which  terminated 
in  recovery.  In  all  such  cases  other  and  more  conclusive 
physical  and  mental  signs  are  abundant;  and  while  the 
ophthalmoscope  will  continue  to  remain  a  valuable  instru- 
ment of  research,  it  is  in  no  sense  an  absolute  test,  and  only 
in  insanity  with  organic  disease  a  collateral  sign  of  value.* 

The  observation  of  the  electro-muscular  reactions 
has  led  to  many  interesting  and  to  some  contradictory  re- 
sults. In  the  present  state  of  science  it  has,  like  the  retinal 
examinations,  a  positive  value  only  in  insanity  with  organic 
disease.  It  is  found,  aside  from  this,  that  all  forms  of  in- 
sanity in  which  irritation  and  excitement  predominate,  are 
marked  by  exaggerated  irritability  of  the  muscles,  which, 
however,  may  pass  to  the  other  extreme  in  maniacal  ex- 
haustion.    Exaggerated    reaction    is   found   in   mania  and 


*  In  pubescent  insanity  and  other  forms  of  alienation,  with  which  mas- 
turbation is  a  marked  factor,  the  writer  has  found  extreme  pallor  of  the 
optic  disk.  But  this  pallor  he  has  found  in  a  much  more  intense  devel- 
opment in  a  sane  masturbator  who  had  such  a  degree  of  retinal  an^emia 
that  he  had  gross  limitation  of  the  field  of  vision,  without  structural 
change. 


68  INSANITY. 

agitated  melancholia,  diminished  reaction  in  atonic  melan- 
cholia, dementia,  stuporous  insanity,  and  katatonia.  But 
these  reactions  may  vary  in  different  parts  of  the  body,  and 
it  has  even  been  noticed  that  the  reaction  differs  on  oppo- 
site sides  of  the  body  in  melancholiacs.  The  finer  ques- 
tions of  electro-diagnosis  are  covered  by  the  question  of 
the  existence  or  non-existence  of  central  organic  disease, 
and  of  certain  metallic  intoxications  which  are  sometimes 
complicated  by  insanity  (saturnine  insanity)  and,  as  thus 
far  determined,  they  have  no  unquestioned  bearing  on  the 
problems  of  insanity  proper. 

Disturbances  of  sensibility  are  frequent  in  insanity. 
Anaesthesia  and  analgesia  may  be  so  pronounced  in  de- 
mented patients,  that  severe  burns  and  traumatic  injuries 
are  not  appreciated  by  them.  Hyperaesthesia  and  paraes- 
thesia  are  often  found  in  mania;  hyperalgesia  harmonizing 
with  the  painful  emotional  state  is  sometimes  a  feature  of 
melancholia. 

Jolly,  Benedict,  and  others  have  vainly  endeavored  to  as- 
sociate the  existence  of  hallucinations  with  disturbed  reac- 
tion of  the  auditor}^  nerve;  but  nothing  could  be  very  much 
more  fallacious  than  the  theory  of  the  former,  that  the  hal- 
lucination of  whole  sentences  heard  in  the  voice  of  some 
person  known  to  the  subject  during  an  electrical  examina- 
tion, indicated  a  disturbance  of  the  auditory  nerve.  Such 
disturbances  essentially  involve  the  organ  where  complex 
hallucinations  can  be  alone  evolved — the  cortex  of  the  cere- 
bral hemispheres. 

In  paretic  dementia  of  the  "ascending  type,"  the  sensory 
disturbances  of  locomotor  ataxia  are  appreciable,  even 
before  the  mental  symptoms  are  well  developed.  The  well- 
known  laryngologist,  Elsberg,  passing  through  the  writer's 
office,  recognized  a  patient  whom  some  years  before  he  had 
treated  for  a  throat  catarrh,  and  remarked  that  he  had 
rarely  seen  an  instance  of  such  pronounced  laryngeal  anaes- 
thesia as  this  patient  then  presented.  The  patient  later 
showed  signs  of  the  incipient  stage  of  a  second  exacerba- 
tion of  paretic  dementia,  and  there  was  no  other  anaesthesia 
than  this  one  discoverable  then;  subsequently  general  anaes- 
thesia and  ataxia  became  marked. 

In  many  instances  the  determination  of  sensibilitj^  is 
rendered  impossible  by  the  dementia,  the  atony,  the  rest- 
lessness, and  sometimes  the  delusional  mutism  of  pa- 
tients. 


PHYSICAL    INDICATIONS   OF   ACQUIRED   INSANITY.  69 

Howard,  of  Montreal,  claims  that  anaesthesia  is  pro- 
nounced in  epileptic  and  other  forms  of  dementia. 

A  great  deal  has  been  written  about  the  composition  of 

THE    BLOOD     AND    THE    URINE    IN    INSANITY,   but  little    of    this 

literature  is  of  interest  to  the  practitioner.  While  there  are 
those  whose  enthusiasm  for  new  therapeutic  measures,  and 
whose  ignorance  of  the  true  nature  of  insanity,  led  them 
to  believe  that  the  vitiated  blood  composition,  which  they 
supposed  the  foundation  of  all  forms  of  mental  disorder, 
could  be  removed  together  with  the  insanity  by  transfu- 
sion; scarcely  less  absurd  propositions  have  been  made, 
based  on  the  alleged  fact  that  the  phosphates  are  continu- 
ously being  drained  from  the  brain  in  insanity,  and  pass 
out  in  the  urine.* 

It  is  true  that  changes  in  the  blood  composition  occur  in 
insanity.  Without  committing  ourselves  to  the  view  of 
Sutherland,  that  the  non-agglutination  of  the  blood-corpus- 
cles in  rows  is  an  indication  of  certain  forms  of  alienation, 
and,  remarkably  enough  too — as  that  author  claims — more 
constantly  an  evidence  of  insanity  in  the  male  than  in  the 
female  patient,  it  may  be  conceded  that  anaemia  of  an  ex- 
treme kin(i,  sometimes  reaching  the  degree  of  a  pernicious 
anaemia,  is  a  feature  of  insanity  with  depression  and  stupor, 
as  well  as  of  apatlietic  dementia.  But  even  in  melancholia, 
particularly  in  that  variety  which  is  termed  melancholia  sine 
delirio  (see  Melancholia),  the  writer  has  failed  to  find  any 
anomaly  of  the  general  nutrition,  the  blood  composition  or 
the  secretions  in  several — exceptional — instances.  Exclud- 
ing the  fatal  forms  of  insanity  and  those  above  mentioned, 
the  anaemia  of  asylum  inmates  is  not  so  much  more  marked 
than  in  the  corresponding  poor-house  or  tenement-house 
population,  as  to  constitute  a  valuable  criterion  of  insanity. 
It  is  when  present  a  noteworthy  collateral  phenomenon,  and 
rarely  anything  else. 


*The  suggestion  of  a  writer  in  the  American  Journal  of  Insanity,  that 
phosphorus  is  to  the  brain  in  insanity  what  iron  is  to  the  blood  in  anaemia, 
is  probably  an  outgrowth  of  the  theory  that  a  fat  patient  is  a  cured  pa- 
tient, and  that  the  terms  "convalescent  ward"  and  "  feeding  ward"  are 
synonymous,  and  is  in  harmony  with  the  dicta  that  there  "is  no  heredi- 
tary insanity,"  that  no  person  can  be  born  insane,  that  kleptomania  and 
pyromania  are  names  of  crimes,  that  moral  insanity  is  wickedness  and 
not  disease,  and  that  mania  and  melancholia  are  the  same  thing  "psy- 
chologically" and  "pathologically,"  as  claimed  in  the  annual  reports  of 
the  State  Asylum  at  Utica,  where  the  journal  in  question  is  published. 


yo  INSANITY. 

The  scrlid  constituents  of  the  tirine  are  often  increased  in 
insanity,  and  it  is  particularly  in  the  exacerbations  of  pa- 
retic dementia  that  this  increase  becomes  so  marked  as  to 
suggest  the  possible  explanation  of  the  loss  in  weight  ob- 
served at  these  times,  on  the  ground  of  renal  elimination. 
The  old  view  that  it  is  particularly  the  phosphates  which 
are  increased  in  the  urine  of  patients  suffering  from  excite- 
ment, and  that  this  is  the  expression  of  a  chemical  exhaus- 
tion of  the  brain,  is  not  borne  out  by  more  recent  and  care- 
ful examinations.  In  the  writer's  experience  it  is  unusual 
to  find  the  increase  of  phosphates  in  the  urine  of  the  insane 
to  exceed  the  limits  found  in  patients  suffering  from  spinal 
irritation  and  the  masturbatory  neurosis. 

In  those  forms  of  insanity  and  their  episodial  outbreaks 
in  which  there  are  marked  changes  in  the  blood-pressure, 
albuminuria  is  frequently  and  hyaline  casts  are  occasionally 
observed.  This  is  the  case  with  the  maniacal  and  apoplec- 
tiform phases  of  paretic  dementia,  the  post-convulsive  epi- 
leptic states,  and  acute  alcoholic  insanity. 

While  the  examinations  of  the  various  organs  and  fluids 
above  alluded  to  have  rather  a  collateral  than  a  fundamen- 
tal value,  those  of  the  circulatory  apparatus,  though  they 
have  not  yielded  any  indications  of  insanity  destined  to  oc- 
cupy a  place  side  by  side  with  what  are  after  all  the  im- 
portant and  essential  signs  of  insanity:  the  mental  disturb- 
ances; they  have  at  least  pointed  out  paths  of  research 
which  if  conscientiously  followed  will  enlighten  us  as  to  the 
real  nature  of  the  maniacal  and  the  melancholic  attack,  and 
of  the  exacerbations  of  paretic  dementia.  It  is  well  known 
that  the  pulse-trace  is  modified  in  health  by  various  emo- 
tional states,  and  it  is  in  harmony  with  this  that  the  sphyg- 
MOORAPHic  EXAMINATION  in  insanity  connected  with  dis- 
turbed vaso-motor  states  reveals  such  suggestive  changes 
from  the  normal  pulse  character. 

In  the  secondary  and  terminal  deteriorations  the  pulse- 
trace  is  that  designated  by  Wolff  as  the  pulsus  tardus:  the 
ascent  is  not  marked  by  a  sharp  apex  as  in  health.  This 
expression  of  the  normal  vascular  tone  is  lost — in  other 
words,  there  is  a  degree  of  vascular  paresis.  In  mania  there 
is  as  a  rule  normal  and  variable  tension,  while  in  acute  de- 
lirium there  is  a  rapid  deterioration  of  the  pulse-trace,  which 
ultimately  becomes  monocrotic,  with  the  apex  of  the  ascent 
or  percussion  stroke  greatly  rounded,  thus  resembling  the 
pulse  of  the  terminal  states  with  cardiac  anenergy  or  en- 


PHYSICAL   INDICATIONS    OF   ACQUIRED    INSANITY.    7I 

feeblement,  and  with  vaso-motor  paresis.  A  similar  con- 
dition is  found  in  the  later  stages  of  paretic  dementia,  in 
the  earlier  stages  of  which  illness  the  pulse-trace  has  a  dif- 
ferent character,  to  be  hereinafter  referred  to. 

The  TEMPERATURE  OF  THE  INSANE  does  not  present  any 
constantly  marked  variations  except  in  melancholia,  where  it 
is  commonly  what  is  termed  sub-normal,  that  is,  between 
96'5°  and  98°  Fahrenheit  (36*2° — 37°  C.),  and  may  in  stupor- 
ous insanity  and  the  cataleptic  phases  of  katatonia  sink  to 
95°  and  less,  gradually  diminishing  with  a  fatal  termination. 
In  paretic  dementia  it  varies  within  narrower  limits  and  in 
different  directions  in  the  various  types  and  phases  of  that 
disease.  Howard,  of  Montreal,  claims  that  the  lowering  of 
the  temperature  in  insanity  generally,  is  more  common  than 
the  writer  is  able  to  admit;  but  it  seems  from  his  figures 
that  prolonged  insomnia  may  lead  to  a  lowering  even  in 
maniacal  disorders.  As  a  rule  the  temperature  is  altogether 
normal  in  simple  mania,  and  even  in  the  most  violent  frenzy 
of  that  psychosis  when  the  forehead  to  the  touch  appears 
to  indicate  a  fever-heat,  the  thermometer  may  not  show  a 
higher  temperature  than  that  found  in  the  sane.  The  not 
inconsiderable  variation  of  the  temperature  in  the  sane,* 
and  its  quite  constant  decrease  in  old  age,  should  be  taken 
into  account  in  attributing  a  value  to  the  temperature  varia- 
tions in  insanity.  Marked  variations  in  this  disorder  arc 
probably  due  to  involvement  of  the  cortical  thermic  centres. 

The  functions  of  the  intestinal  tract  show  great  dis- 
turbances in  some  forms  of  insanity.  Indeed,  the  ancients 
and  those  recent  alienists  of  the  somatic  school  of  Jacobi,  ac- 
cording to  whom  the  os  sacrum  covered  more  of  the  seat  of 
insanity  than  the  os  frontis,  were  inclined  to  believe  that 
because  insanity  was  sometimes  averted  or  otherwise  favor- 
ably influenced  by  a  brisk  cathartic,  that  visceral  disorders 
might  be  the  primary  factor  in  the  production  of  insanity. 
Others,  like  the  renowned  Van  der  Kolk,  were  induced  to 
divide  all  forms  of  insanity  into  two  groups,  idiopathic 
and  sympathetic,  according  as  their  primary  origin  was 
supposed  to  be  in  the  brain,  or  in  some  other  organs,  notably 
the  viscera.  It  is  now  generally  admitted  that  in  the  vast 
majority  of  cases  the  essential  foundation  of  insanity  is  in 
the  brain,  and  that  only  exceptionally  do  peripheral  disturb- 
ances cause  or  materially  modify  the  disorder.     When  the 

*  Determined  by  Landon  Carter  Gray,  of  Brooklyn. 


72  INSANITY. 

same  set  of  hypochondriacal  delusions  is  found  in  two 
brothers,  both  of  whom  are  found  in  the  autopsy  to 
present  the  same  constriction  of  the  intestinal  canal, 
the  hasty  guess  might  be  made  that  a  common  cause 
—  a  visceral  disorder — had  produced  the  same  mental  dis- 
turbance in  both,  whereas  in  reality  insanit}'  was  hereditary 
in  the  cases  alluded  to,  and  the  visceral  disturbance  was  as 
much  a  modifying  factor  as  any  other  accidental  circum- 
stance, affecting  the  brothers  equally,  might  have  been. 

In  atonic  mental  states  the  atony  of  the  general  muscu- 
lar periphery  is  shared  by  the  intestinal  muscular  tube  as 
well  as  by  the  oesophagus.  Under  these  circumstances  diffi- 
culty or  inability  to  swallow,  tympanitic  distension  and  con- 
stipation are  present.  These  conditions  may  alternate  with 
an  adynamic  form  of  diarrhoea,  a  most  undesirable  compli- 
cation of  the  stuporous  and  melancholiac  states:  while  in 
mania  a  slight  diarrhoea,  due  to  a  different  condition;  over- 
activity of  the  normal  peristaltic  movements;  is  neither  an 
uncommon  nor  an  unfavorable  symptom.  In  that  variety 
of  melancholia  in  which  there  is  atonic  contraction  of  all 
the  muscles,  manifesting  itself  in  a  "  frozen  attitude"  and 
tetanic  contraction  of  the  facial  muscles,  there  exists  a  simi- 
lar tonic  spasm  of  the  intestinal  tube  and  even  of  the  urin- 
ary bladder;  the  former  leading  to  constipation,  the  latter 
to  spastic  dysuria. 

Anomalies  of  the  appetite,  such  as  anorexia,  which  is 
characteristic  of  the  atonic  and  depressive  forms  of  insanity, 
and  the  bulimia,  or  ravenous  appetite  of  mania  and  the  ma- 
niacal phases  of  paretic  dementia,  are  partly  of  direct  psy- 
chical origin,  or  the  indirect  results  of  the  mental  state  as 
manifested  in  secondary  atony  or  anaesthesia  of  the  stom- 
ach. 

The  condition  of  the  skin  and  its  secretions  is  some- 
times greatly  altered  in  insanity.  The  skin  may  be  dry  and 
parchment-like,  particularly  in  melancholia;  in  all  atonic 
states  it  has  a  clammy  feel,  and  in  dementia  maybe  exceed- 
inglv  oilv.  In  mania  the  skin  is  more  apt  to  be  moist.  The 
so-called  effluvium  of  the  excited  insane  is  due  to  their  ex- 
increased  cutaneous  secretions  and  the  decomposition  of 
the  sudor  and  macerating  epithelium.  It  has  not — in  the 
writer's  experience — anything  characteristic;  and  probabh' 
those  observers  who  consider  themselves  able  to  diagnos- 
ticate mania  with  their  regio  olfactoria  have  done  so  on 
the  strength  of  an  unanalyzed  experience  in  the  maniacal 


PHYSICAL   INDICATIONS   OF   ACQUIRED   INSANITY.   73 

wards.  Here  there  is  indeed  an  odor  rarely  encountered 
elsewhere,  but  it  is  due  to  a  combination  of  the  odors  of 
other  excretions  with  those  of  the  skin,  which  is  rarely  en- 
countered in  ordinary  hospitals.  Keep  a  maniacal  patient 
clean,  give  him  a  frequent  change  of  linen,  and  he  will  not 
present  anything  specially  indicating  his  disorder  to  the 
sense  of  smell !  With  certain  idiots  a  musky  odor  has  been 
observed  by  an  Italian  alienist,  and  it  is  more  reasonable  to 
suspect  a  specific  change  here  than  in  the  acute  psychoses. 

Some  believe  that  the  hands  of  patients  addicted  to  mas- 
turbation are  remarkably  clammy  and  blue  in  contrast  with 
the  rest  of  the  body.  This  fact,  which  is  borne  out  by  the 
writer's  experience,  is  probably  due  to  the  enfeeblement  of 
the  distant  capillary  circulation  in  these  patients,  and  is  not 
peculiar  to  this  condition,  but  is  found  in  stupor  and  mel- 
ancholia as  well. 

The  motor  disturbances  in  insanity,  intimately  allied  as 
these  are  with  the  mental  symptoms,  and  indeed  often 
rather  of  a  psychical  than  of  a  strictly  somatic  nature,  are 
among  its  most  prominent  indications.  In  the  case  of  at 
least  three  forms  of  insanity  the  absolute  diagnosis  cannot 
be  made  when  certain  motor  symptoms  are  absent,  i.e.,  in 
paretic  and  syphilitic  dementia  and  in  the  alcoholic  forms. 
And  in  many  other  instances,  as  in  the  motor  agitation  of 
mania,  the  atony  and  catalepsy  of  other  forms  and  the  auto- 
matic movements  of  the  states  of  mental  enfeeblement,  they 
constitute  characteristic  features  of  the  psychoses. 

Paresis  of  a  peculiar  type  is  found  in  paretic  and  syphi- 
litic dementia,  and  also  after  acute  delirium,  as  the  result  of 
destructive  lesion  of  the  nerve-centres.  Contractures  may 
similarly  result,  while  convulsions  may  be  among  the  first 
indications,  as  they  are  almost  constantly  found  to  be  among 
the  last  accompaniments,  of  paretic  dementia.  The  con- 
vulsions found  with  epileptic,  the  peculiar  movements  oc- 
curring with  choreic  and  hysterical  psychoses,  as  well  as  the 
motor  and  co-ordination  disturbances  of  insanity  resulting 
from  sclerosis,  tumors,  and  meningitis,  are  to  be  excluded 
as  not  being  genuine  evidences  of  the  insanity  itself,  for 
they  are  all  found  in  epilepsy,  chorea,  hysteria,  sclerosis, 
tumors  and  meningitis  without  insanity. 

Ataxia  is  a  frequent  phenomenon  of  paretic  dementia, 
and  characterizes  one  of  its  types;  aphasia  and  anaesthesia 
are  likewise  common  in  this  disorder,  which  is  a  perfect 
repertory  of  all  possible  motor  disturbances. 


74  INSANITY. 

The  muscular  over-activity  of  mania  and  the  muscular 
passiveness  of  melancholia  are  psychical  expressions  of 
these  mental  states,  and  will  be  considered  with  them. 

A  tetanic  condition  of  the  muscles  is  found  in  a  number 
of  atonic  melancholiacs,  and  its  disappearance  without  co- 
incident amelioration  of  the  mental  symptoms  is  an  indica- 
tion that  the  patient  will  not  recover,  but  is  passing  into 
pa  sive  dementia. 

Tlie  cataleptic  state  of  the  muscles  is  one  of  the  character- 
istic features  of  katatonic  insanity. 

A  special  interest  attaches  to  the  innervation  of  the  facial 
muscles  in  all  forms  of  insanity;  to  the  experienced  alienist 
there  are  no  more  suggestive  signs  of  mental  disorder  than 
the  insane  exp?'ession,  manner  and  attitude.  This  is  not  to  be 
wondered  at.  What  is  a  more  faithful  indicator  of  a  con- 
dition— which,  however  morbid,  is  at  bottom  a  mental  one — 
than  the  thoughts  and  their  expression  in  the  patient  ? 
Just  as  the  play  of  the  facial  muscles,  the  expression  of  the 
eye,  the  movements  and  attitude  of  tlie  body,  are  indications 
of  the  emotions,  and  to  experienced  mind-readers  of  the 
very  thoughts  of  the  sane;  so  the  animated  or  angry  ex- 
pression of  the  maniac,  the  sad  and  thoughtful  gaze  of  tlie 
melancholiac,  the  blank  face  of  the  stuporous  and  tlie  silly 
countenance  of  the  pubescent  lunatic  are  indications  to  the 
practical  alienist  of  the  form  of  insanity  with  which  he  has 
to  deal.  Indeed,  in  the  absence  of  written  or  spoken  men- 
tal symbols  in  certain  cases,  the  expression  and  attitude 
of  the  patient  are  the  leading  indications  of  his  insanity. 
They  acquire  a  special  value  from  the  fact  that  the  most 
expert  actor  finds  no  sign  of  insanity  so  difficult  to  feign  as 
the  insane  expression.  Insane  thought  documents  itself 
not  in  words  and  writings  alone.  The  monomaniac  who 
believes  himself  a  king  betrays  it  in  his  vain  attitude  and 
supercilious  scowl;  the  paretic  dement  who  thinks  himself 
a  millionaire  assumes  a  lofty  step;  the  erotomaniac  ex- 
hibits an  affectionate  look,  the  religious  lunatic  that  of  a 
fanatic,  a  zealot  or  a  mystic,  while  the  nymphomaniac  be- 
trays her  condition,  if  not  in  every  gesture,  in  every 
glance. 

In  those  forms  of  insanity  which  will  be  considered 
under  the  head  of  terminal  deteriorations,  in  some  imbe- 
ciles, and  more  rarely  in  monomaniacs,  peculiar  movements 
are  observed,  which  are  without  purpose,  but  which  it  seems 
the  patient  has  to  go  through  with,  as  if  driven  by  some 


PHYSICAL   INDICATIONS   OF   ACQUIRED    INSANITY.    75 

unseen  power.  Samuel  Johnson,  who  was  a  case  of  mono- 
mania with  imperative  conceptions,  was  thus  found  one  day 
in  Twickenham  meadow,  surrounded  by  a  laughing  mob, 
amused  at  the  great  lexicographer's  sitting  astride  a  book 
and  imitating  the  motions  of  a  jockey  riding  at  full  speed. 
On  other  occasions  it  was  noted  that  this  man  could  not  go 
through  a  certain  street  without  touching  every  post  on  the 
way,  and  if  he  forgot  one,  he  turned  back  to  make  good  the 
omission.  On  crossing  a  certain  threshold  he  regularly 
turned  a  pirouette,  etc.  Asylum  inmates  exhibit  similar 
odd  movements;  some  will  go  through  movements  very 
like  the  genuflections  and  crossings  or  self-castigations  of  a 
religious  devotee,  without  being  able  to  assign  any  reasons 
for  doing  so;  others  will  walk  in  a  certain  circle,  triangle, 
or  square,  and  bring  down  their  feet  with  special  emphasis 
at  given  intervals;  still  others  appear  to  be  continually 
brushing  away  something.  As  all  these  movements  are 
disconnected  in  their  motive  from  the  thoughts  of  the  pa- 
tient, and  are  thus  analogous  to  the  imperative  conception 
(Chapter  III.),  they  are  termed  imperative  movements.  Some 
believe  that  they  have  their  origin  in  delusions,  which  are 
obliterated  by  dementia,  only  the  movements  remaining 
and  becoming  a  habit.  But  this  explanation  certainly  does 
not  cover  many  cases,  particularly  such  as  Johnson's. 

Another  class  of  movements  is  found  in  idiotic,  imbecile 
and  extremely  demented  patients:  these  are  the  automatic 
rhythmical  movements.  Patients  of  the  kind  mentioned  may 
for  months  exhibit  the  same  movement  when  awake,  either 
in  oscillation  of  the  entire  body  from  side  to  side,  or  from 
before  backward,  or  of  the  head,  the  eyes,  the  mouth  or 
the  hands  alone. 

The  pupil  exhibits  marked  deviations  from  the  normal 
standard  in  insanity.  In  passive  melancholia,  katatonia, 
pubescent  and  stuporous  insanit}'^,  it  is  equally  dilated, 
sometimes  to  a  maximum  degree.  A  dilated  and  mobile 
pupil  is  also  very  generally  met  with  among  epileptics.  In 
aged  patients  and  with  certain  anomalies  of  refraction  this 
may  be  greatly  modified,  and  alcoholic  epileptics  and  alco- 
holic melancholiacs  may  have  medium-sized  or  even  narrow 
pupils.  In  mania  the  pupils  are  either  normal  or  contracted, 
and  only  in  mania  from  starvation  are  they  dilated.  Kirn 
has  observed  an  initial  pupillary  spasm  in  periodical  mania, 
while  in  katatonia,  the  writer  has  observed  a  disappearance 
of  the  dilatation  as  the  patient  passed  out  of  the  cataleptic 


'J^  INSANITY. 

State,  spontaneously,  as  well  as  when  this  occurred  under 
the  influence  of  nitrite  of  amyl. 

While  in  all  the  conditions  thus  far  named  the  pupillary 
changes  are  not  much  greater  than  those  occurring  in  the 
non-insane  population,  in  paretic  dementia  they  have  a  high 
diagnostic  value.  Extreme  initial  myosis  and  irregular 
contraction,  followed  by  paresis  of  the  sphincter,  are  very 
frequent  accompaniments  of  this  disorder,  and  sometimes 
indications  of  the  precise  phase  of  its  progress. 

Speech  disturbances  in  insanity,  aside  from  those  due  to 
organic  disease,  involve  changes  in  the  rhythm  and  manner 
of  speaking,  and,  like  the  facial  expression  of  the  patient, 
indicate  the  nature  of  his  disorder  to  some  extent,  aside 
from  the  actual  contents  of  his  sayings.  Thus  a  rapid  flight 
of  words  is  a  marked  feature  of  mania  and  the  maniacal 
phases  of  paretic  dementia,  while  a  slow,  impeded  speech 
is  observed  in  melancholia  and  dementia,  and  this  sinks  to 
absolute  mutism  in  the  stuporous,  atonic,  and  cataleptic 
states,  as  it  also  does  under  the  influence  of  overpowering 
delusions  and  in  hysterical  insanity. 

The  "verbigeration"  of  katatonia  and  the  "echolalia"  of 
imbecility  are  rather  psychical  than  motor  manifestations 
in  their  essence  and  will  be  considered  with  the  special 
forms. 

Just  as  the  contents  of  insane  documents  are  of  great 
value  in  determining  the  nature  of  a  suspected  mental  dis- 
order, so  the  hanchvriting  of  the  insane  in  itself  exhibits  many 
suggestive  peculiarities.  In  those  forms  of  insanity  which 
are  marked  by  motor  disturbance,  a  peculiar  tremulous  char- 
acter of  the  handwriting  is  manifested;  in  monomania  the 
paper  is  covered  with  underlining  marks,  queries,  exclama- 
tion points,  dashes,  and  strange  symbols.  Some  patients 
write  almost  microscopically  fine,  others  very  coarsely,  still 
others  combine  these  extremes  in  one  and  the  same  docu- 
ment; while  one  patient  in  the  writer's  observation  used 
the  same  page  six  times,  writing  once  transversely,  then  lon- 
gitudinally from  top  to  bottom,  then  longitudinally  from 
bottom  to  top,  then  upside  down,  and  twice  diagonally.  In 
another  case,  that  of  an  insane  author  who  printed  his  own 
book,  every  form  and  variety  of  type  was  employed  b)'  him; 
and  a  good  example  of  the  manner  in  which  the  symbols 
and  italics  are  abused  by  the  insane  is  furnished  by  a  poem 
of  which  the  following  is  the  conclusion: 


PHYSICAL   INDICATIONS   OF  ACQUIRED    INSANITY.   77 

So  take  this  advice  before  I  go; 

(i  Ah  every  Miser  here  below!) 

And  save  yourself  from  the  horrid  fate — 

When  you  think  to  enter  Heaven's  gate; 

To  be  told  to  stand  aside  and  wait — 

And  let  the  poor  little  child  pass  by, 

i  That  he  left  to  freeze,  and  starve,  and  die  ! 

While  he  had  hugged  the  dross  of  Earth; — 

And  without  pity  saw  it  die! 

And  heedless  saw  its  mother's  eye, 

Sunken  in  sorrow  and  dimmed  by  grief, 

When  he  would  offer  no  relief; — 

Hoarding  life's  blessings  like  a  thief  I 

i  Ah!    C-H-I-N-G-O    C-H-I-N-GO    L-l-N-G  O    L-I-N-K — 

i  Nolu pitches  him  down  to  Hell,  I  think! — 

Where  let  the  miserable  Miser  go! 

Only  fit  for  horrid  Hell  below, 

'Tis  the  doom  he  sought — so  let  him  have  it ! 

The  FIRE  OF  HELL— so  let  him  brave  it ! 

iiii  C-H-I-N-G-O!    iC-H-I-N-G-o!    i  L-I-N-G-O!    i  L-I-N-K  !!!!! — 

l—iu.  13034  ???— ] 

The  writer  has  also  observed  analogous  oddities  in  the 
compositions  of  an  insane  musician,  who,  writing  a  "  money- 
polka,"  had  a  peculiar  symbol  inserted  among  the  notes, 
indicating  that  at  such  and  such  a  point  bags  of  money 
must  be  jingled  to  the  tune.  But  these  formal  aberrations 
in  writing  are  motor  expressions  of  morbid  projects,  and 
rather  belong  to  the  strictly  psychical  indications  of  insan- 
ity. They  are  here  referred  to  only  because  it  is  customary 
to  regard  the  handwriting  and  its  mannerisms  in  the  insane 
together. 

The  trophic  disturbances  of  insanity  in  the  widest 
sense  comprise  the  congenital  anomalies  to  be  considered 
in  the  next  chapter,  as  well  as  that  general  nutritive  dis- 
turbance of  insanity,  which  manifests  itself  as  a  rapid  loss 
of  weight  in  melancholia  and  stupor,  a  less  considerable 
loss  in  mania,  as  an  alternating  loss  and  gain  in  circular 
insanity,  and  in  rare  instances  as  a  progressive  pernicious 
anaemia.  The  congenital  anomaliesare  indications  of  the  evil 
influence  of  arrested  or  perverted  development  of  the  brain 
in  peripheral  development,  and  the  acquired  trophic  dis- 
turbances are  the  outcome  of  the  profound  influence  which 
the  matured  brain  exerts  on  the  bodily  states.  Recently 
the  term  trophic  disturbance  has  come  to  be  used  in  a  more 
limited  sense,  excluding  the  above,  and  in  this  sense  as  ap- 
plying only  to  positive  and  local  manifestations  of  deranged 
nutrition  and  growth  the  term  will  be  here  considered. 


78  INSANITY. 

Like  other  gross  signs  of  nervous  disease  the  trophic  dis- 
turbances are  most  varied  in  character  and  constant  in  oc- 
currence with  insanity  associated  with  organic  disease.  A 
peculiar  change  in  the  bones,  by  which  these  either  become 
unduly  brittle,  or  so  soft  that  a  knife  suffices  to  divide  them 
(in  one  instance  in  the  writer's  experience,  to  cut  the  cal- 
varium  in  places  and  to  open  the  thorax)  is  found  in  about 
a  quarter  of  the  patients  suffering  from  advanced  paretic 
dementia.  Not  unfrequently  charges  of  violence  and  abuse 
are  based  on  these  spontaneous  conditions,  which  latter  are 
entirely  dependent,  like  the  changes  which  occur  in  the  artic- 
ular extremities  of  the  long  bones  in  locomotor  ataxia,  on 
irritative  and  destructive  lesions  of  the  brain  and  spinal 
cord.  Almost  the  entire  train  of  trophic  disturbance  found 
in  disease  of  the  spinal  cord — muscular  lipomatosis  and 
deuteropathic  muscular  atrophy,  phlegmonous  ulcers,  bul- 
lae, atonic  decubitus,  and  that  malignant  decubitus  which 
spreads  with  such  remarkable  rapidity  as  to  defy  all  efforts 
of  treatment — are  all  found  in  paretic  dementia. 

Herpetic  and  other  eruptions,  peculiar  forms  of  pigmen- 
tation, premature  grayness,  and  particularly  the  blanch- 
ing of  the  hair  in  unilateral  or  S)'mmetrical  patches,*  have 
been  observed  in  acute  insanity,  and  in  one  instance  in  the 
writer's  experience,  that  of  a  negro  paretic,  a  blanching  of 
the  skin  in  irregular  anastomozing  patches,  was  observed 
just  prior  to  an  accelerated  progression  of  the  disease. 

A  noteworthy  trophic  disturbance  is  that  known  as 
Othematoma.  This  consists  in  the  formation  of  a  san- 
guineous tumor  of  the  external  ear.  Anatomically  it  con- 
sists of  a  haemorrhage  into  the  substance  of  the  aural  carti- 
lage proper,  and  is  probably  due  to  a  diseased  state  of  this 
cartilage  or  its  vessels;  though  the  possibility  of  its  pro- 
duction by  violence  alone  cannot  be  excluded,  for  this  event 
has  been  recorded  by  good  observers  as  occurring  in  sane 
subjects.  The  writer  has  been  struck  by  the  fact  that  in 
large  pauper  asylums  with  few  attendants,  and  those  of  an 
undesirable  class,  and  with  large  numbers  of  ill-fed  and 
irritated  patients  crowded  in  the  wards,  the  physicians 
were  able  to  show  numerous  cases  of  othaematoma;  while 
in  private  institutions  and  continental  asylums  there  was 
sometimes    not  a  single  recent  case  to  be  found,  and  the 

*  Also  observed   in   spinal   irritation   with   predominant    vaso-motor 
symptoms. 


PHYSICAL   INDICATIONS    OF   ACQUIRED   INSANITY.    79 

scars  of  those  who  had  had  othaematomata  frequently  dated 
from  a  sojourn  in  some  infirmary  or  other  less  well-managed 
institution.  Whatever  the  fact  may  be,  it  is  generally  ad- 
mitted that  if  violence  is  a  factor  in  producing  othaematoma, 
it  is  a  subsidiary  one  to  the  structural  predisposition  of  the 
patient's  tissues.  Injuries  which  would  fail  to  produce  any 
noticeable  reaction  in  the  sane,  produce  othaematoma  in 
certain  lunatics. 

This  symptom,  also  termed  the  ''insane  ear,"  was  found 
in  48  out  of  2,297  patients  by  Kiernan.  He  found  it  with 
every  form  of  insanity  except  with  monomania,  which 
was  not  at  that  time  differentiated  from  secondary  confu- 
sional  insanity  by  this  observer.  It  seems  to  be  least  com- 
mon in  melancholia  and  most  common  in  epileptic,  paretic 
and  terminal  dementia,  and  has  been  occasionally  observed 
to  herald  the  approach  of  a  delirious  exacerbation.  Othae- 
matoma, from  its  common  occurrence  in  incurable  forms  of 
insanity,  has  been  considered  of  grave  import,  but  it  is  not 
in  itself  of  prognostic  value,  and  a  few  cases  of  acute  in- 
sanity have  been  reported  to  end  in  recovery,  although  this 
symptom  was  present.*  It  is  now  generally  considered  to 
be  a  collateral  trophic  disturbance  of  insanity  which  may 
require  special  treatnient,  but  which  has  no  intrinsic  signi- 
fication. If  uninterfered  with,  the  tumor  undergoes  shrink- 
age, the  blood  is  absorbed,  and  great  deformity  results. 
This  sequel  may  be  to  a  great  extent  avoided  by  making 
numerous  small  punctures  over  the  most  prominent  por- 
tions of  the  tumor,  and  cleaning  out  the  half-clotted,  half- 
fluid  dark  blood  and  tissue  debris  constituting  its  contents. 
If  it  should  be  shown  that  othaematomata,  when  found  in 
terminal  or  paretic  dements,  imbeciles,  and  epileptics,  are 
as  constantly  associated  with  blood  cysts  of  the  arachnoid, 
as  the  author  has  found  to  be  the  case  in  a  limited  number 
of  examinations,  this  sign  may  attain  a  relative  value  of  a 
kind  which  cannot  now  be  assigned  to  it. 

With  regard  to  the  sudden  visceral  complications  of  in- 
sanity   occurring  without    any  external    influence    or  local 


*  It  is  significant  that  regarding  the  three  recoveries  which  Kiernan 
observed  among  forty-eight  patients  with  othaematomata,  that  author,  in 
a  copy  of  his  paper,  sent  the  writer  two  years  subsequent  to  its  publica- 
tion, inserted  marginal  manuscript  notes  to  the  effect  that  all  three  pa- 
tients subsequently  returned  to  the  asylum;  one  as  a  paretic  dement,  a 
second  as  a  melancholiac  dying  in  an  attack  of  raplns  tnelancholicus, 
the  third  as  a  (probably)  periodical  maniac. 


8o  INSANITY. 

cause,  and  frequently  without  a  local  predisposition — such 
as  pulmonary  gangrene,  infarctions,  pleural  ecchymoses, 
haematoma  of  the  lower  bowel,  necrotic  changes  in  other 
organs  distant  from  the  brain — these  are  almost  without 
exception  the  result  of  gross  vaso-motor  and  trophic  influ- 
ences provoked  by  exacerbations  of  the  central  nervous 
affection.  They  hence  follow  the  apoplectiform  and  epi- 
leptiform phases  of  paretic  dementia,  the  seizures  of  epi- 
lepsy, and  the  haemorrhages  and  other  acute  cerebral  com- 
plications of  terminal  dementia.  In  some  instances,  as  in 
the  pulmonary  gangrene  of  acute  insanity,  other  factors, 
such  as  general  disturbances  of  nutrition  and  pulmonary 
atelectasis  from  respiratory  stagnation,  may  participate  in 
the  production  of  the  lesion. 

It  is  of  considerable  medico-legal  importance  that  in  the 
insane,  black  and  blue  marks  of  a  kind  resembling  bruises 
may  appear  spontaneously.  In  some  cases  these  marks 
approximate  a  marbled  character;  they  are  not  as  linear 
in  direction  as  marks  made  by  blows  with  a  stick  or  strap, 
and  hence  cannot  be  readily  confounded  with  the  marks 
produced  by  such  implements.  But  trifling  bruises  and 
mere  pressure  may  produce  marks  resembling  the  latter 
in  demented  patients. 

In  one  form  of  insanity — delirium  grave — the  trophic 
disturbances  are  so  marked  in  all  patients  who  live  any 
considerable  length  of  time,  that  they  may  be  considered 
among  the  characteristic  signs  of  that  disease.  They  re- 
semble the  changes  noted  by  Mitchell  after  peripheral 
nerve-injuries,  and  by  others  after  cerebral  hemiplegia. 
(See  Delirium   Grave). 

In  some  phases  and  forms  of  insanity,  notably  in  the  ear- 
lier stages  of  paretic  dementia,  it  has  been  found  that 
wounds  and  ulcers  heal  with  remarkable  rapidity,  more 
quickly  by  far  than  in  health.  With  this  the  general  nutri- 
tion of  the  patient  appears  to  be  in  an  excellent,  if  not  an 
extravagant,  condition.  Later  in  the  same  disease  the  re- 
verse occurs:  slight  injuries  are  followed  by  rapid  and  de- 
structive sloughing,  and  with  this  there  is  a  general  deteri- 
oration of  the  bodily  state. 

In  maniacal  conditions  a  favorable  influence  of  the  in- 
sanity on  existing  bodily  diseases  has  been  frequently  ob- 
served; a  convincing  proof,  if  such  proof  were  needed,  that 
the  cant  that  all  lunatics  are  "  sick  men,"  in  the  sense 
that  their  bodily  mal-nutrition,  irrespective  of  the  condi- 


SIGNS    OF   THE   INSANE   CONSTITUTION.  8 1 

tion  of  the  cerebral   organ,  is  the  foundation  of  their  in- 
sanity, is  not  justified  by  conscientious  observations. 

While — as  repeatedly  insisted  on  in  this  chapter — no  even 
approximately  scientific  study  of  insanity  can  be  made  with- 
out a  consideration  of  the  bodily  states  often  accompanying 
it;  yet,  for  the  purposes  of  diagnosis  and  psychological,  as 
well  as  medico-legal  analysis,  the  mental  symptoms  and 
those  somatic  signs  which  are  directly  indicative  of  or 
parallel  to  the  mental  symptoms  will  forever  occupy  the 
position  of  the  essential  signs  of  alienation.  A  delusion,  an 
imperative  conception,  a  faulty  logic,  a  disordered  emotional 
state,  will  always  prove  a  more  profitable  discovery  to  the 
diagnostician  than  an  anaemia,  a  constipation,  a  bed-sore, 
or  an  excess  of  chlorides  in  the  urine.  And  among  the 
physical  signs  those,  which,  like  the  movements,  the  hand- 
writing, and  the  facial  expression,  are  the  direct  outcome 
of  the  mental  state,  have  a  more  convincing  diagnostic  and 
prognostic  value  than  the  disturbed  phenomena  of  vegeta- 
tive life. 


CHAPTER  IX. 


Somatic  Signs  of  Insanity  Indicating  the  Existence  of 
A  Constitutional  Taint  of,  or  a  Predisposition  to, 
Insanity. 

Individuals  are  sometimes  born  with  so  defective  a  ner- 
vous organization  that  as  soon  as  the  first  manifestations 
of  higher  mental  life  appear,  or  should  appear,  the  defec- 
tive or  perverted  anatomical  foundation  exhibits  its  nefari- 
ous influence  in  the  defective  or  perverted  state  of  the  mind. 
Such  persons  may  properly  be  said  to  be  born  insane,  and 
though  the  quibble  may  be  made  that  a  being  cannot  be  said 
to  be  of  non-sane  mind  before  its  mind  is  developed,  it  may 
be  safely  assumed,  that  where  the  essential  foundation  of 
insanity  is  present  the  elements  of  insanity  positively  exist; 
just  as  club-foot,  although  perchance  the  child  may  never 
have  attempted  to  nor  ever  will  walk  and  exhibit  the  func- 
tional manifestation  of  its  organic  difficulty,  is  properly 
considered  a  disorder  of  the  organs  of  locomotion. 

But  even  the   quibble  alluded  to  can  be   met   by  facts. 


S2  INSANITY. 

Just  as  children  may  be  born  affected  with  chorea,  eclamp- 
sia, hydrocephalus,  and  a  large  number  of  other  diseases; 
so  cases  have  been  recorded,  however  rare  they  may  be, 
where  mental  derangement  was  observed  from  birth.  As 
might  be  anticipated  such  derangement  is  manifested  in 
the  instinctive  and  reflex  spheres.  Idiots  are  observed  to 
have  a  more  stupid  look  than  other  children,  and  sometimes 
to  be  unable  to  suck;  others  are  found  to  exhibit  odd  mo- 
tions or  fits  of  furious  violence,  and  Greding  records  the 
instance  of  the  child  of  an  insane  woman  which  had  fits  of 
destructive  mania  at  its  ninth  month,  and  died  with  them 
before  the  end  of  its  first  year  of  life.  As  a  rule,  the  func- 
tional expression  of  the  insane  brain  in  childhood  is  in 
convulsions;  a  fact  in  parallelism  with  the  daily  observa- 
tion that  the  febrile  deliria  of  the  adult  are  in  infants  often 
replaced  by  convulsive  spells. 

Organic  diseases  of  the  brain,  such  as  meningitis,  hydro- 
cephalus, and  cerebral  syphilis,  developing  either  before  or 
after  birth,  lead  to  irregularities  in  development  which 
functionally  ma}'  manifest  themselves  in  insanity,  and  or- 
ganically in  anomalies  of  the  skull  shape,  of  dentition,  and  of 
peripheral  development.  The  earlier  the  time  of  the  in- 
jury the  more  serious  its  results,  and  this  applies  above  all 
to  those  errors  or  flaws  of  development  which  occur  in 
members  of  a  degenerating  family  line;  that  is,  one  in 
which  insanity  of  a  certain  tj'pe  or  any  grave  neurosis  has 
already  been  developed. 

Both  paternal  and  maternal  influences  are  active  in  de- 
termining the  conformation  of  the  offspring,  but  the  rela- 
tive preponderance  of  maternal  influence  in  hereditary 
transmission  is  almost  a  dogma  of  Natural  History.  Ma- 
ternal influences  being  concerned  in  the  maturation  of  the 
ovum,  a  process  lasting  many  years,  and  the  development 
of  the  impregnated  ovum  to  maturity,  it  is  easily  under- 
stood why  a  healthy  male  influence,  limited  to  a  briefer 
period  of  the  germ-history,  should  be  less  potent  to  neu- 
tralize the  evil  influence  of  a  vitiated  female  parentage, 
than  a  healthy  maternal  influence  is  to  neutralize  the  influ- 
ence of  a  morbid  or  aberrant  male  ancestry.  This  finds  a 
confirmation  in  the  conclusions  of  Ricliarz, 

1.  The  chances  of  the  transmission  of  insanity  are  greater 
if  the  mother  is  mentally  affected,  than  if  the  father  is  in- 
sane. 

2.  The  chances  of  transmission  are  greater  for  that  child 


SIGXS    OF   THE   INSANE   CONSTITUTION.  83 

which  is  of  the  same  sex  as,  and  which  resembles  the  insane 
person. 

The  same  author,  after  a  careful  study  of  numerous 
cases,  established  the  following  order  of  liability  to  insane 
inheritance: 

Mother  insane,  i.  The  daughter  resembling  the  mother(?) 

"  2.  The  son  resembling  the  mother. 

"  3.  The  daughter  resembling  the  father. 

"  4.  The  son  resembling  the  father. 

Father  insane.  5.  The  son  resembling  the  father. 

"  6.  The  daughter  resembling  the  father. 

"  7.  The  daughter  resembling  the  mother(?) 

"  8.  The  son  resembling  the  mother(?) 

It  is  scarcely  necessary  to  add  that  the  liability  to  insan- 
ity is  still  greater  when  both  parents  are  insane  or  have  a 
nervous  disorder;  and  that  conception  during  an  exacer- 
bation of  their  illness  *  or  in  the  event  of  consanguinity 
almost  renders  its  transmission  a  certainty. 

That  the  transmission  of  many  of  the  cerebral  defects, 
with  which  the  alienist  is  concerned,  occurs  in  some  way  at 
the  moment  of  conception,  although  the  exact  manner  of 
the  transmission  will  never  become  known,  is  the  general 
surmise  of  those  who  have  studied  the  subject.  Far  more 
certain  is  our  knowledge  concerning  the  embryonic  mech- 
anism of  these  defects,  and  of  the  influence  which  foetal  and 
maternal  impressions  and  injuries  exert  on  the  develop- 
ment of  the  nerve-centres.  The  latter  knowledge  furnishes 
valuable  arguments  by  analogy  in  support  of  the  accepted 
conclusions  regarding  the  hereditary  group.  Modern  em- 
bryologists  have  gone  so  far  as  to  imitate  the  known  natural 
teratological  malformation  of  the  nerve-centres  through  ar- 
tificial methods.  By  wounding  the  embryonic  and  vascular 
areas  of  the  chick's  germ  with  a  cataract  needle  malforma- 
tions are  induced,  varying  in  intensity  and  character  with 
the  earliness  of  the  injury  and  its  precise  extent.  More 
delicate  injuries  produce  less  monstrous  development,  and 
it  is  particularly  the  partial  varnishing  or  irregular  heating 
of  the  eggshell  that  results  in  the  production  of  anomalies 
comparable  to  microcephaly  and  cerebral  asymmetry.  It 
is  this  latter  fact,  showing  the  constancy  of   the  injurious 

*  Just  as  children  conceived  by  a  drunken  father  have  been  repeatedl)r 
found  to  be  epileptic,  imbecile,  deaf  mute,  or  insane. 


84  INSANITY. 

effect  of  so  apparently  slight  an  impression  as  the  partial 
varnishing  of  a  structure  not  directly  connected  with  the 
embryo,  that  may  suggest  the  line  of  research,  or  rather  of 
reasoning,  to  be  followed  in  seeking  for  a  plausible  expla- 
nation of  the  maternal  and  other  impressions  acting  on  the 
human  germ.  What  delicate  problems  are  to  be  solved  in 
this  connection  may  be  inferred  from  the  observation  of  Da- 
reste,  that  eggs  transported  in  railroad  cars  and  subjected 
to  the  vibration  and  repeated  shocks  of  a  railroad  journey 
are  checked  in  development  for  several  days.  It  requires 
no  great  stretch  of  the  fancy  to  imagine  a  less  coarse, 
molecular  transmission  to  take  place  during  the  maturation 
of  the  ovum,  or  its  fertilization,  or,  finally,  the  embryonic 
phases  of  the  more  complex  and,  therefore,  more  readily 
disturbed  and  distorted  human  germ,  and  thus  to  account 
for  the  disastrous  effects  of  insanity,  emotional  explosions, 
and  mental  or  physical  shocks  of  either  parent,  on  the  off- 
spring. 

All  doubts  as  to  the  potency  of  maternal  impressions  to 
affect  the  shape  of  the  foetal  body  and  its  organs  must  be 
dispelled  by  such  positive  evidence  as  is  furnished  by  the 
two  following  cases:  one  selected  from  the  domain  of  zo- 
ology (because  of  the  absence  here  of  many  of  the  objec- 
tions which  might  be  made  to  cases  observed  in  the  human 
species),  the  other  from  that  of  an  alienist's  experience. 
At  the  meeting  of  the  Zoological  Society  of  London,  held 
February  24,  1863,  Dr.  C.  E.  Gray,  the  curator  of  the  Brit- 
ish Museum,  presented  the  body  of  a  chicken  whose  beak 
and  feet  closely  resembled  those  of  a  parrot.  The  sender 
of  the  specimen  reported  that  several  such  instances  had 
occurred  in  his  poultry  yard,  and  he  attributed  the  mon- 
strosities to  the  fact  that  one  of  the  hens  had  been  fright- 
ened by  a  parrot  which  was  kept  in  a  cage  in  the  same 
yard,  and  which  had  the  habit,  when  the  hens  approached 
its  cage  for  food,  of  screeching  violently  at  them.  More 
remarkable  in  many  respects  is  the  case  described  by  Wille. 
A  healthy  woman,  while  pregnant  by  a  healthy  husband, 
experienced  a  sudden  fright  at  seeing  a  man  without  a  nose. 
When  her  child  was  born  its  nose  was  found  flattened, 
there  was  harelip,  and,  beside  other  evidences  of  an  early 
defect  in  the  germ  axis  epiblast,  the  cerebral  hemispheres 
were  found  confluent  in  the  middle  line.  The  writer  had 
under  treatment  a  child  which,  when  first  seen  at  its  nine- 
teenth month,  seemed  to  be  a  forcible  example  of  the  influ- 


SIGNS   OF   THE    INSANE   CONSTITUTION.  85 

ence  of  maternal  visual  impressions  on  the  conformation  of 
the  child.  Its  head  was  noticed  from  birth  to  have  the 
following  peculiarity:  the  frontal  region  being  excessively 
narrow,  the  greater  part  of  the  skull  cavity  seemed  to  be 
crowded  behind  the  ears.  The  narrowing  of  the  frontal 
region  was  unsymmetrical,  the  left  frontal  bone  appearing 
as  if  not  half  the  area  of  its  fellow,  and  exhibiting  a  de- 
pression extending  into  the  left  temporal  region,  while  the 
ocular  aperture  on  that  side  was  less  wide  than  its  fellow. 
Before  the  writer's  assuming  charge  of  the  case  it  had  had 
for  three  months  from  ten  to  thirty  epileptiform  attacks 
daily,  which  ceased  after  five  days,  under  the  use  of  bro- 
mides and  proper  dietetic  treatment.  The  child  was  then 
absolutely  idiotic;  it  was  at  last  accounts  weak-minded,  and 
altogether  an  "  enfant  arriere,"  had  not  learned  to  walk  at 
its  twenty-second  month,  and  exhibited  violent  outbursts  of 
temper  at  times.  Owing  to  strabismus  (deficiency  of  inner 
and  inferior  recti^  it  did  not  then  appear  to  use  its  eyes  at 
all.  At  last  reports  it  managed  to  render  its  ocular  axes 
parallel  by  carrying  its  head  in  an  oblique  position  toward 
the  object  it  desired  to  fixate.  The  only  cause  the  healthy 
mother  was  able  to  assign  was  a  sudden  fright  experienced 
by  her  during  a  panic  on  board  a  steamer  a  few  weeks  be- 
fore the  infant  was  born.  But  as  the  deformity  in  question 
must  have  originated  at  a  much  earlier  period  of  gestation, 
and  as  the  whole  physiognomy  of  the  child  was  an  almost 
caricature-like  reproduction  of  one  of  its  father's  features, 
it  seems  more  reasonable  to  attribute  the  deformity  to  a 
visual  impression.  The  father  sustained  an  injury  of  the 
left  eye  years  ago,  and  the  palpebral  aperture  being  closed, 
the  whole  side  appeared  contracted,  though  in  reality  there 
was  no  cranial  asymmetry  in  his  case.  In  all  these  and  simi- 
lar cases  the  embryonic  disturbance  extends  far  deeper  than 
the  deformity  of  the  subject  seen  by  the  mother — an  evi- 
dence that  the  injurious  influence  has  partially  revolution- 
ized the  germ-layer  arrangements  and  proportions.  A 
striking  example  of  the  influence  of  maternal  conditions  of 
another  kind  is  furnished  by  Herbert  Sankey,  where,  in  a 
somewhat  neurotic  family,  all  the  children  were  normal  ex- 
cept two,  with  whom  the  mother  had  had  severe  epileptiform 
convulsions  while  enceinte. 

One  of  the  strongest  arguments  in  support  of  the  view 
which  refers  the  hereditar)'-  and  congenital  constitutional 
insanities  to  anatomical  defects   is  furnished    by  the   great 


86  INSANITY. 

analogy  existing  between  the  transmission  of  these  insani- 
ties and  the  known  phenomena  of  inheritance  studied  by 
zoologists.  Some  of  the  resemblances  have  been  already 
referred  to;  a  most  important  one  is  the  frequent  intensifi- 
cation of  the  malady  as  well  as  of  the  anatomical  defects. 
For  example,  in  an  observed  case,  a  father  was  merely  mor- 
bidly eccentric,  and  presented  no  cranial  anomaly  indicat- 
ing an  anatomical  mal-development.  His  child,  however, 
became  an  original  monomaniac,  and  had  asymmetry  of  the 
cranium  and  defects  of  innervation,  indicating  such  mal- 
development.  In  another  instance  a  monomaniac,  of  very 
good  education  and  marked  ability  in  many  directions,  who 
is  now  out  of  the  asylum  and  engaged  in  chemical  experi- 
mentation and  the  occasional  issue  of  insane  pamphlets, 
had  an  idiotic  daughter,  with  a  deformed  cranium  and 
strabismus,  who  died  early  with  convulsions.  It  must  be 
admitted  that  such  cases  strongly  support  the  suspicion  that 
the  anomaly  visible  in  the  descendant  pre-exists  in  the  par- 
ent in  so  slight  a  degree  that  it  remains  impalpable  to  our 
imperfect  methods  of  examination. 

While  the  misshapen  bodies,  the  deformed  ears,  the  an- 
omalies of  the  sexual  apparatus,  and  of  dentition,  some- 
times found  in  lunatics  of  the  "  degenerative  series,"  have 
a  bearing  on  the  question  of  the  inheritance  of  insanity  and 
properly  rank  as  among  the  somatic  stigmata  and  diagnos- 
tic marks  of  that  disorder;  special  interest  attaches  to  the 
peculiarities  of  the  insane  skull,  as  an  index  of  the  dis- 
turbed development  of  the  mental  organ  contained  within. 

The  attention  of  observant  visitors  passing  through  the 
wards  of  an  asylum  for  the  insane  is  often  directed  to  the 
large  proportion  of  the  inmates  exhibiting  anomalies  of  the 
cranial  configuration.  Aside  from  a  number  of  cases  where 
the  skull  is  either  perceptibly  above  or  below  the  average 
in  all  its  dimensions,  and  another  series  in  which  the  cra- 
nial asymmetry  is  grossly  exaggerated,  there  are  found 
others  where,  either  separately  from  these  aberrations  or 
coexistent,  there  are  discovered  extreme  brachycephaly 
or  dolichocephaly,  flattening  of  one  or  the  other  end  of  the 
cranial  ovoid,  disproportions  between  the  dome  and  the 
base,  promontory-like  extensions  of  the  vault,  in  short,  . 
every  conceivable  deviation  from  that  standard  which  the 
experience  of  anatomists  with  sane  subjects  justifies  us  in 
considering  as  the  normal  one. 

The  question  naturally  arises,  whether  a  relation  can  be 


SIGNS   OF   THE    INSANE    CONSTITUTION.  8/ 

established  between  these  anomalies  of  the  cranium  and 
the  presence  of  their  bearers  in  an  asylum.  Most  of  the 
classical  writers  assume  the  existence  of  such  a  relation, 
and  content  themselves  with  noting  the  coincidence  of 
mental  alienation  in  general,  with  cranial  malformation. 
Foville  the  elder,  after  excluding  cases  of  idiocy  and  cretin- 
ism from  the  list,  found  that  one  sixth  of  his  insane  pa- 
tients presented  marked  cranial  malformation.  Morel  was 
the  first  to  refer  to  an  intrinsic  relation  between  the  char- 
acter of  the  insanity  and  the  associated  cranial  anomalies. 
He  established  the  special  frequency  of  the  latter  with  the 
hereditary  and  degenerative  forms.  The  same  anomaly,  a 
peculiar  flattening  of  the  occiput,  was  found  in  thirteen  sub- 
jects presenting  the  symptoms  of  the  manie  raisonnante  of  the 
French.  A  different  malformation,  characterized  by  flat- 
tening and  depression  of  the  forehead,  with  an  increase  of 
the  transverse  diameter  of  the  skull,  has  been  noted  as  being 
of  special  frequency  with  insanity  manifesting  itself  in  homi- 
cidal, suicidal,  and  other  dangerous  impulses.  The  ste- 
notic skull  has  been  as  frequently  observed  with  congenital 
weak-mindedness,  associated  with  mental  and  motor  agita- 
tion. Among  special  symptoms  none  appear  to  be  so 
commonly  associated  with  a  particular  cranial  deformity  as 
pyromania.  The  Germans  have  found  osteophytes  on  the 
sella  turcica,  and  abnormal  prominency  of  the  clivus  projec- 
tion in  the  dead,  and  distortions  of  the  cranium  in  the  liv- 
ing subject,  which  pointed  to  a  basilar  deformity  in  several 
of  those  exhibiting  this  impulse.  The  crania  progenia  have 
been  found  in  subjects  representing  connecting  links,  as  it 
were,  between  idiocy  and  monomania.  But  pronounced 
asymmetry  of  the  skull  is  found  to  be  less  constantly  asso- 
ciated with  special  forms  of  derangement;  very  frequent 
with  epilepsy  and  epileptic  insanity,  it  is  a  not  uncommon 
accompaniment  of  monomania  and  imbecility. 

Lasegue  and  Garel  established  the  existence  of  a  close 
relation  between  idiopathic  epilepsy  and  faulty  ossification 
of  the  cranial  sutures  with  resulting  asymmetry.  Morel 
found  the  latter  as  frequently  in  the  degenerative  forms  of 
insanity.     It  is  quite  common  in  chronic  insane  epileptics. 

The  combination  of  cranial  deformities  with  such  differ- 
ent forms  of  insanity  seems  little  calculated  to  explain, 
per  se,  the  character  of  the  connection  between  the  visible 
anomaly  and  the  mental  aberration.  That  the  cranial  de- 
formity is  merely  the  expression  of  an  error  in  development,. 


88  INSANITY. 

simultaneously  affecting  the  organ  of  the  mind,  and  that 
herein  its  signification  really  consists,  is  almost  self-evident. 
But  before  this  line  of  inquiry  can  be  profitably  followed 
certain  clinical  relations  must  be  clearly  grasped  whose 
accentuation  at  this  point  hence  becomes  necessary. 

The  defective  states  of  the  mind,  which  are  the  frequent 
manifestations  of  an  hereditarily  transmitted  taint,  may  be 
ranged  in  a  serial  chain,  whose  links  are  constituted  by 
different  forms  of  alienation,  and  merge  gradually  into  one 
another.  One  end  of  this  chain  is  constituted  by  idioc}^  the 
other  by  that  systematized  perversion  of  the  intellect,  which, 
classed  by  the  great  Esquirol  under  the  too  often  misinter- 
preted designation  of  monomania,  is  now  known  variously 
as  megalomania,  chronic  delusional  insanity,  primary  intel- 
lectual vesania,  and  by  a  host  of  other  terms,  more  or  less 
correctly  expressing  some  prominent  feature  of  this  form 
of  mental  alienation.  On  first  sight  these  two  conditions 
would  appear  to  be  separated  by  an  impassable  chasm,  and 
this  from  a  psychological,  as  well  as  from  a  strictly  somatic 
point  of  view.  No  greater  contrast  could  be  exhibited 
within  the  walls  of  an  as3'lum  than  by  placing  side  by  side 
an  idiot  and  a  lunatic  wnth  systematized  projects  and  de- 
lusions: on  the  one  hand  there  is  a  state  characterized  by 
an  utter  absence  of  every  higher  menial  co-ordination;  on 
the  other,  one  which  manifests  intricate  and  varied  combi- 
nations of  the  mental  mechanism,  which  are  analogous  to 
those  of  the  normal  mind.  In  the  former  case,  the  gross 
anatomical  defect,  which  is  in  such  perfect  parallelism  with 
the  mental  hiatus  evident,  is  usually  perceivable  on  the  first 
glance;  in  the  other,  no  deviation  from  the  normal  physique 
may  be  discoverable  with  our  available  methods  of  exami- 
nation. 

On  studying,  however,  other  cases  of  insanity  arising  in 
the  course  of  hereditary  transmission,  there  are  found  cer- 
tain groups,  for  w^hich  it  is  justifiable  to  claim  a  place,  in- 
termediate to  that  occupied  by  the  two  extreme  forms  men- 
tioned. They  are  composed  of  cases  of  imbecility,  with  or 
without  morbid  impulsiveness,  and  others  with  primary 
delusional  insanity  united  with  weak-mindedness  as  a 
prominent  factor.  On  inquiring  yet  more  profoundly  into 
the  mutual  relation  of  these  different  forms,  and  including 
in  the  analysis  those  transmitted  insanities  associated  with 
epileptic  manifestations  and  with  moral  imbecility,  observers 
have  perceived  that  not  only  is  there  an  uninterrupted  sin- 


SIGNS   OF   THE    INSANE    CONSTITUTION.  89 

gle  line  of  gradation  running  from  idiocy  to  primary  in- 
sanity with  systematized  delusions,  but  that,  in  addition, 
there  are  numerous  collateral  branches  springing  from  this 
parent  stem  at  certain  altitudes,  which  crop  out  into  more 
or  less  independent  developments.  It  is,  hence,  not  pos- 
sible to  draw  an  absolute  line  of  demarkation  between  the 
different  forms  comprising  this  series.  The  more  exten- 
sive observations  become,  the  clearer  is  it  recognized  that 
there  exist  transition  forms  uniting  into  one  great  class  all 
the  hereditary  insanities.  Startling  as  these  propositions 
seem  when  advanced  thus  categorically,  they  are  not  in 
their  essence  new  ones.  Cloaked  in  less  decided  language, 
their  expression  maybe  traced  in  the  writings  of  the  earlier 
masters  of  mental  pathology. 

As  far  as  positive  data  have  been  obtained  in  the  pathol- 
ogy of  hereditary  and  congenital  insanity,  many  of  the 
cases  coming  under  this  head  constitute  a  united  group, 
characterized  and  held  together  as  an  anatomico-pathologi- 
cal unity  by  the  presence  of  a  teratological  anomaly.  Morel 
recognized  the  affiliation  existing  between  most  of  these 
groups,  and  identified  their  somatic  resemblance  in  the 
common  presence  of  the  hereditary  stigmata.  His  researches 
did  not  extend  to  a  minute  study  of  the  brain.  Le  Grand 
du  Saulle,  in  a  masterly  series  of  papers,  affirmed  the  propo- 
sitions of  his  great  predecessor,  and  fortified  them  chiefly 
by  clinical  observation.  Krafft-Ebing,  in  his  earlier  mono- 
graph on  the  criminal  jurisprudence  of  the  insane,  laid 
great  stress  on  the  importance  of  tlie  stigmata  and  especial- 
ly of  cranial  deformity  in  the  recognition  of  certain  heredi- 
tary and  doubtful  cases  of  insanity.  More  recently  he  has 
drawn  the  line  very  sharply  and  happily  between  the  "psy- 
cho-neuroses," as  he  terms  the  ordinary  forms  of  insanity 
developed  in  individuals  in  whom  no  degenerative  taint 
exists,  and  the  "  psychical  degenerative  states"  which  com- 
prise the  greater  part  of  the  cases  with  which  the  stigmata 
are  found. 

The  conventional  notion  of  idiocy  and  imbecility — the 
forms  which  stand  at  the  lower  end  of  the  degenerative 
series — associating  these  conditions  with  a  simply  quanti- 
tative deficiency  of  the  fore-brain,  is  a  very  imperfect  one. 
The  researches  of  numerous  observers  have  shown  that 
qualitative  defects,  using  the  term  "qualitative"  in  its 
wider  sense  to  cover  both  morphological  and  histological 
aberrations,  are  at  least  as  common  and  perhaps  more  char- 


90  INSANITY. 

acteristic  features  of  the  idiotic  and  imbecile  brain, and  are 
for  the  most  part  as  closely  related  to  the  cranial  malfor- 
mation. These  defects  may  be  enumerated  under  the  fol- 
lowing heads: 

1.  Atypical  asymmetry  of  the  cerebral  hemispheres,  as  re- 
gards bulk. 

2.  Atypical  asymmetry  in  the  gyral  development. 

3.  Persistence  of  embryonic  features  in  the  gyral  arrange- 
ment. 

4.  Defective  development  of  the  great  inter-hemispheric 
commissure. 

5.  Irregular  and  defective  development  of  the  great  gan- 
glia and  of  the  conducting  tracts. 

6.  Anomalies  in  the  development  of  the  minute  elements 
of  the  brain. 

7.  Abnormal  arrangement  of  the  cerebral  vascular  chan- 
nels. 

All  of  these  conditions  are  separately,  or  in  the  combina- 
tion of  several  of  the  features  above  mentioned,  occasionally 
found  in  the  brains  of  lunatics,  appertaining  to  the  group 
of  monomania,  or  so-called  "  partial  insanity."  They  are 
also  and  more  constantly  found  in  that  mixed  and  unclassi- 
fied group  of  cases  clinically  occupying  an  intermediate 
position  between  the  higher  systematized  perversions  of  the 
mind  falling  under  the  designation  of  monomania,  and  the 
lower  group  of  congenital  imbecility.  Inasmuch  as  the 
latter  cases  almost  universally  exhibit  a  pronounced  mal- 
formation of  the  cranium,  and  in  all  the  instances  which 
have  been  thoroughly  examined — with  the  result  of  reveal- 
ing cerebral  defects — such  malformation  was  a  prominent 
feature,  it  may  not  be  unwarrantable  to  anticipate  the  ex- 
istence of  cerebral  defects,  where  similar  external  malfor- 
mations are  discovered  during  life. 

,  There  are  undoubtedly  cases  of  insanity  of  inherited 
origin,  in  which  cerebral  defects  are  not  discoverable.  In- 
stead of  conflicting  with  the  views  to  be  expressed  in  the 
present  chapter,  this  fact  furnishes  on  the  contrary  a  strong 
support  of  them.  What  is  more  natural  than  that  in  a 
series  of  cases,  ranging  between  idiocy  with  its  gross  and 
palpable  physiological  defects,  and  monomania  with  its  rel- 
atively close  analogies  to  physiological  cerebration,  a  cor- 
responding structural  gradation,  insensibly  approaching 
the  normal  limits,  should  exist?  The  general  conclusion 
that  the  explanation  of  the  existence  of  a  certain  class  of 


SIGNS   OF   THE    INSANE    CONSTITUTION.  9 1 

the  hereditary  insanities  and  the  basis  of  the  manifested 
symptoms  is  to  be  sought  for  in  morphological,  that  is,  in 
^;<'i2'i-/-teratological  faults  of  structure  and  not  in  post-natal 
changes,  happens  to  harmonize  with  every  clinical  experi- 
ence. 

Authors  have  given  much  prominence  to  the  alleged  fact 
that  a  transformation  in  the  type  of  a  given  hereditary  neu- 
rosis is  the  rule.  It  is  true  that  such  a  transformation  fre- 
quently occurs;  that  an  epileptic  parent  may  have  an  imbe- 
cile child,  that  a  monomaniacal  ancestor  may  have  an  idiotic 
or  a  deaf-mute  descendant,  while  a  father  suffering  from  alco- 
holism  may  have  an  epileptic  son.  It  is  also  true  that  the 
'superhcial  features*"of  neural  disorder  in  the  child  may  be 
the  very  opposite  of  those  found  in  the  parent.  But  a  closer 
study  shows  that  the  occasional  observation  of  the  latter 
fact  has  been  made  the  basis  of  too  wide  a  generalization. 
It  is  particularly  in  the  case  of  monomania  that  a  great 
similarity  in  the  manifestations  is  found  in  an  entire  insane 
familv  branch,  r^icidal  T-pnrhirl  impnkp'^  \\^ve  been  ob- 
served to  be  transmitted  with  such  constancy,  that  although 
the  fact  that  the  suicide  of  his  ancestors  at  a  certain  age 
had  been  faithfully  kept  from  a  patient  inheriting  this  ten- 
dency, and  the  possibility  of  imitation  was  thus  excluded, 
he  committed  suicide  at  about  the  same  period  of  life  which 
had  been  the  fatal  one  with  his  ancestry. 

The  readiness  with  which  any  one  of  the  various  mental 
and  nervous  disorders  may  undergo  a  metamorphosis  into 
another  form,  in  the  course  of  hereditary  transmission, 
seems  interpretable  in  only  one  way.  It  is  to  be  assumed 
that  a  change  in  the  nature  of  the  transmitted  structural 
defects  or  their  intensification  or  mitigation  may  account 
for  such  a  transformation.  Thus  asymmetry  of  the  brain 
and  skull  are  found  in  hereditary  epilepsy  and  in  hereditary 
monomania,  but  it  is  not  yet  known  in  what  particular  di- 
rection the  asymmetry  must  be  manifested  to  determine  one 
or  the  other  of  these  conditions. 

The  frequent  association  in  a  given  family  line  of  the 
periodical  psychoses  in  some,  and  epilepsy  in  other  mem- 
bers, is  a  suggestive  one,  as  both  disorders  are  manifesta- 
tions of  vaso-motor  states. 

The  erroneous  idea  has  been  inculcated  in  several  treatises, 
that  as  soon  as  the  degenerative  psychoses  have  once  mani- 
fested themselves  m  a  given  family  line,  the  course  of  that 
line  is  infallibly  in  the  direction   of  further  degeneration 


92  INSANITY. 

and  extinction.  This,  while  true  in  a  large  number  of  cases, 
is  not  so  with  regard  to  all.  For  example,  the  Austrian 
philosopher,  Schopenhauer,  had  imbecile  relatives  n 
^  ancestry!  Fhis  instance,  like  tne  sometimes  noted  appear- 
ance of  a  one-sided  talent  or  genius  in  a  mentally  unsound 
family,  illustrates  the  occasional  triumph,  however  partial 
that  triumph  may  be,  of  the  conservative  and  progressive 
over  the  degenerative  tendencies. 


CHAPTER  X. 

The  Morbid  Anatomy  of  Insanity. 

The  interesting  question  whether  there  are  pathogno- 
monic signs  of  insanity  in  the  dead  as  well  as  in  the  living 
body,  is  a  natural  sequel  to  the  two  foregoing  chapters. 
The  examination  of  the  living  patient  reveals  the  manifesta- 
tions of  a  morbid  state;  the  existence  of  somatic  signs  and 
stigmata  su^s^gests  its  nature;  but  it  is  only  the  anatomical 
and  physiological  methods  which  are  calculated  X.o  prove  the 
intifnate  relation  between  this  state,  if  demonstrable,  and  the 
symptoms  depending-on  it. 

Let  the  reader  reflect  for  one  moment  on  the  presumable 
degree  of  intensity  which  a  lesion  must  reach  in  order  to 
affect  the  mental  faculties  !  Let  him  bear  in  mind  that  the 
majority  of  the  symptoms  of  insanity  are  merely  excesses 
or  deficiencies  or  perversions  of  functions — excesses,  defi- 
ciencies, and  perversions  whose  very  existence  implies  that 
their  organic  basis  must  be  anatomically  intact!  He  will  then 
recognize  the  futility  of  searching  for  coarse  formative 
changes  in  such  subtle  affections  as  most  of  the  simple 
primary  pyschoses  are.  It  is  well  established  that  fatal 
brain  intoxication  can  be  produced  by  conium,  opium,  and 
chloroform,  without  producing  any  changes  in  the  nerve 
structures  proper  which  the  microscopist  is  able  to  detect. 
And  we  need  not  wonder  that  with  the  presumably  grosser 
dissociation  of  the  nervous  molecules  which  takes  place  at 
the  moment  of  death,  some  of  those  finer  changes  which 
are  compatible  with  life,  though  sufficient  to  produce  men- 
tal disturbance,  should  be  obliterated,  just  as  similarly  deli- 


THE    MORBID   ANATOMY   OF   INSANITY.  93 

cate  changes  are  obliterated  in  death  from  acute  hydropho- 
bia, tetanus,  and  strychnia  poisoning. 

In  a  large  number  of  cases  where  the  functional  dis- 
turbance reaches  a  high  degree,  or  continues  for  a  long 
period,  tissue  changes  occur,  either  in  the  way  of  a  primary 
lesion  of  the  nerve  elements,  or  of  vascular  degeneration 
with  its  ensuing  result:  tissue  mal-nutrition.  These  changes 
when  found  often  furnish  valuable  indications  as  to  the 
original  nature  of  the  insanity  with  which  they  exist.  It  is 
to  be  regretted,  however,  that  the  study  of  these  lesions  has 
been  hampered  by  premature  theorization  and  erroneous 
observation  to  an  extent  which  is  unparalleled  in  medicine. 

On  account  of  the  dearth  of  constant  pathological  find- 
ings in  cases  of  insanity,  the  earlier,  and  some  contemporary 
pathologists  have  been  reduced  to  remarkable  extremities 
in  endeavoring  to  assign  insanity  to  material  causes,  or  to 
explain  certain  of  the  symptoms  of  insanity  on  material 
grounds.  Some  of  the  resulting  errors  are  no  doubt  due 
to  the  fact  that  those  who  have  committed  them  have  not 
had  as  large  a  material  of  normal  subjects  at  their  disposal 
as  would  have  enabled  them  to  determine  the  extent  of 
normal  variation.  One  alienist,  for  example,  claims  as  a 
pathological  fact,  that  the  sciatic  nerve  is  flattened  in 
general  paralysis  of  the  insane;  yet  this  nerve  is  always  a 
flat  cord,  and  variably  so,  in  normal  subjects.  Two  other 
writers  find  certain  cells  of  the  parietal  region  and  its 
neighborhood  to  be  "  pathologically  enlarged  "  in  special 
forms  of  insanity;  yet  over  eight  years  ago  Betz  demon- 
strated that  just  such  cells  constitute  the  nests  of  gigantic 
pyramids  in  that  very  region  of  the  normal  cortex.  Their 
absence,  not  their  presence,  would  be  abnormal! 

Much  as  is  to  be  eliminated  from  our  pathological 
records,  as  accidental  or  artificial,  those  records  become 
still  further  reduced,  when  we  attribute  a  proper  value  to 
the  registration  by  alienists  of  certain  vascular  and  other 
histological  appearances  as  lesions  of  insanity  which  are 
found  in  every  healthy  adult.  The  more  delicate  changes 
in  the  adventitia  of  the  cortical  blood-vessels,  deposits  of 
haematozin  and  granular  matter  in  their  neighborhood,  and 
pigmentation  of  certain  nerve-cells,  it  can  be  positively 
affirmed,  are  constant  occurrences  in  subjects  dying  sane, 
and  who  have  never  been  anything  but  sane.  Only  when 
these  changes  pass  a  certain  degree  can  they  be  attributed 
to  insanit5\     It  is  also  to  be  borne   in   mind   that  many 


94  INSANITY. 

actually  morbid  appearances  in  the  insane  are  not  neces- 
sarily related  to  the  mental  disorder  as  such.  These  are 
prominently  the  atheromatous  change  of  the  blood-vessels 
and  the  so-called  miliary  aneurism.  Both  occur  at  least  as 
frequently  and  in  the  same  distribution  in  the  sane  popula- 
tion as  in  the  insane,  and  the  clinical  signification  of  both 
changes  is  so  thoroughly  well  known  and  appreciated  that 
their  potency  to  produce  those  symptoms  of  mental  aliena- 
tion, which  occur  equally  well  in  insane  subjects  with  healthy 
blood-vessels,  may  be  questioned. 

In  many  cases  of  advanced  insanity,  particularly  •with 
the  so-called  secondary  states  and  terminal  dem.entias,  nu- 
merous morbid  appearances  are  found,  W'hich,  while  they 
bear  an  unquestionable  relation  to  the  mental  state  of  the 
patient  as  it  was  preceding  his  demise,  have  no  real  etio- 
logical signification;  established  years  after  the  inception 
of  the  insanity,  they  must  be  considered  as  secondary,  and 
frequenth'  as  passive  results.  The  so  called  arachnoid  cysts, 
and  many  instances  of  a  moderate  degree  of  cerebral  atrophy, 
are  of  this  character. 

The  value  of  our  psycho-pathological  litei^ature  is  also 
impaired  by  the  fact  that  many  of  the  "  lesions"  recorded 
by  observers  have  been,  not  the  result  of  disease,  but  of 
imperfect  manipulation.  A  recent  German  observer,  for 
example,  describes  gaps  in  the  white  substance  of  the  cere- 
bral hemispheres  of  paretics,  which  the  writer,  with  Mendel, 
can  only  consider  to  be  artefacta.*  Another  source  of  error 
is  the  action  of  frost  on  the  partially  hardened  brain. 
When  a  high  degree  of  cold  is  reached,  tlie  entire  organ 
becomes  riddled  with  cracks  and  falls  apart;  with  lesser 
degrees,  the  natural  spaces,  such  as  the  pericellular  and 
perivascular  gaps,  become  much  exaggerated  by  the  ex- 
pansion of  the  fluid  within  them  in  the  freezing  process, 
thus  simulating  the  results  of  long-continued  obstruction 
to  the  lymph  outflow. 

But  the  most  remarkable  error  that  has  been  committed 
in  this  direction  is  one  which,  from  the  fact  that  it  has  been 
made  the  basis  of  a  very  sweeping  and  misleading  generali- 
zation, deserves  special  mention  at  this  point.  Several  of 
the  earlier  pathologists  described  bodies  known  as  "colloid 


"  The  writer  uses  this  term  to  designate  appearances  produced  by  the 
art  of  the  investigator  as  contradistinguished  from  genuine  morbid  ap- 
pearances. 


THE    MORBID   ANATOMY   OF   INSANITY.  95 

^spheres"  and  "  miliary  sclerotic  patches"  as  found  in  the 
insane  brain.  These  bodies,  as  the  writer  has  shown,  can 
be  produced  by  the  action  of  alcohol. 

When  the  brain  or  cord  of  any  animal  is  submitted  to 
the  action  of  this  fluid  a  sufficient  length  of  time  a  peculiar 
series  of  changes  occurs,  simulating  lesions,  but  which  can 
be  produced  at  will  in  the  healthiest  human  and  animal 
brains.  In  the  first  place,  alcohol  has  been  long  known  to 
extract  leticifi  from  nervous  tissues,  and  the  writer  has 
found  crystalloid  or  sub-crystalline  spheres  of  leucin  scat- 
tered more  or  less  regularly  through  the  tissues  or  accumu- 
lated in  the  perivascular  areas  of  healthy  brains  submitted 
to  the  action  of  alcohol.  By  varying  the  length  of  ex- 
posure, or  by  immersing  the  brain,  or  different  portions  of 
the  same  brain,  at  different  stages  of  post-i7iortem  change, 
in  alcohol,  these  artificial  "lesions"  may  be  pleasingly 
varied.  That  these  bodies  are  leucin^  or  at  least  chiefly 
consist  of  Iciiciii,  is  demonstrated  b}''  their  chemical  reac- 
tion. Among  the  tests  which  can  be  conveniently  applied 
are  their  insolubility  in  ether  and  chloroform,  and  difificult 
solubility  in  alcohol  (requiring  1,040  parts  of  cold  and  800 
parts  of  hot  alcohol);  the  bodies  do  not  stain  in  carmine 
and  are  refractive,*  besides  they  are  either  hyaline  or  show 
a  radiatory  striation.f  While  the  observers  in  question 
committed  an  error  in  manipulation  merely,  it  remained 
for  two  later  writers  to  build  up  theories  on  these  artificial 
precipitates,  which  deserve  notice,  if  for  no  other  reason 
than  because  they  have  been  considered  the  semi-official 
utterances  of  a  body  of  alienists,  and  have  misled  the  pro- 
fession not  a  little.  The  fact  that  these  bodies  were  found 
or  rather  manufactured  equally  in  "general  paresis,  sub- 
acute mania,  and  chronic  melancholia,"  is  responsible  for 
the  theory,  that  in  insanity  the  alienist  has  to  contend  with 
but  "one  diathesis;"  and  the  same  fact  doubtless  also  fur- 
nished the  grounds  for  the  dogma  emanating  from  the  same 
source  which  regards  "  mania  and  melancholia  as  essen- 
tially the  same  psychologically  and  pathologically."  The 
"lesions"  in  question,  varyingly  designated  as  "granular 
bodies,"   "grumous   granular  matter,"   "encysted   morbid 


*This  feature  varies,  probably  with  certain  admixtures. 

f  Overstaining  sections  containing  these  bodies  in  carmine,  and  par- 
ticularly in  haematoxylin,  does  stain  the  latter;  ordinary  staining  fails  to 
do  so. 


96  INSANITY. 

products,"  "colloid  bodies,"  "globules  of  a  fatty  nature," 
"  nitrogenous  plasma,  proteinaceous  in  its  nature,"  "  miliary 
sclerosis,"  and  "spots,"  have  been  utilized  to  sustain  the 
claim,  that  the  microscope  "unerringly  points  out  the  seat 
of  disease"  in  insanity.*  It  may  be  safely  predicted  that 
these  and  similar  views  will  retain  a  certain  degree  of  value, 
of  at  least  a  historical  character. 

The  views  of  sound  authorities  are  unanimously  to  the 
effect  that  the  connection  between  the  symptoms  and  les- 
ions of  insanity  is  obscure,  and  that  the  cerebral  disease 
underlying  insanity  is  in  many  cases  undiscoverable.  "  Thir- 
ty years  ago  I  would  willingly  have  written  on  the  patho- 
logical cause  of  insanity;  to-day  I  should  not  attempt  as 
difficult  a  task,  so  much  of  uncertainty  and  contradiction 
is  there  in  the  results  of  post  moriems  made  on  the  insane 
to  this  very  day."  Thus  wrote  the  great  Esquirol  half  a 
century  ago.  Onef  of  the  contemporar}'  French  alienists, 
after  citing  this  passage,  adds:  "  Wliat  Esquirol  said  at  the 
time  he  wrote,  that  might  he  have  adiiered  to  to  this  day, 
notwithstanding  the  incontestable  progress  which  has  been 
made  more  recently  in  the  pathology  of  mental  diseases. 
Although,  during  the  last  few  years,  experimental  physiol- 
ogy, pathological  anatom}',  and  histological  researches  have 
yielded  valuable  acquisitions  to  the  pathology  of  the  ner- 
vous sj'^stem,  this  cannot  be  equally  claimed  in  relation  to 
insanity  properly  speaking;  the  clinical  study,  the  direct 
observation  of  patients,  have  contributed  much  more  to 
advance  this  branch  of  science.  It  is  indeed  to-day  possible, 
with  a  large  number  of  diseases  of  the  nervous  system,  to 
establish  the  relation  between  lesion  and  sj^mptom;  this 
approximation  is,  however,  even  to  this  day  almost  impos- 
sible with  tlie  greater  number  of  mental  diseases."  While 
the  two  extracts  here  quoted  fairly  represent  the  views  of 
the  classical  and  modern  French  authorities,  the  following 
almost  identical  citation  indicates  the  state  of  opinion  in 
Germany,  that  land  which  divides  with  France  the  honor  of 
standing  in  the  front  rank  of  mental  medicine.  "In  turn- 
ing to  pathological  anatomy  for  enlightenment,  it  cannot  be 
suppressed  that  in  a  certain  number  of  post  inortems  of  the 
insane,  palpable  morbid  appearances  of  the  brain  are  ab- 


*  Report  of  the  New  York  State  Asylum  at  Utica. 

f  Dagonet:   "  Nouveau  Traite   Elementaire  et  Pratique  des  Maladies 
Mentales." 


THE    MORBID   ANATOMY   OF   INSANITY.  97 

sent.  .  .  .  Experience  teaches  that  it  is  almost  exclusively 
the  primary  forms,  the  first  stages  of  insanity,  in  which  we 
find  nothing  palpable  in  the  autopsy,  and  must  content  our- 
selves with  assuming  anomalies  of  innervation,  blood-distri- 
bution, and  chemical  composition."*  Quotations  of  a  like 
characte-r  might  be  multiplied. 

In  recent  mania,  properly  so  called,  the  acute  mania  of 
English  writers,  a  form  of  insanity  comprising  from  ten  to 
fifteen  per  cent  of  the  admissions  to  a  large  number  of 
asylums  whose  statistics  the  writer  has  collected,  no  devia- 
tion from  the  normal  structural  conditions  has  been  found. 
The  nerve-cells  and  their  fibres  show  absolutely  nothing 
that  can  distinguish  them  from  the  nerve-cells  and  nerve- 
fibres  of  healthy  persons.  The  only  appearance  revealed 
with  any  degree  of  constancy  in  uncomplicated  cases  is  a 
fulness  of  the  cerebral  blood-vessels, f  which  in  extreme  in- 
stances may  be  accompanied  by  haemorrhages  or  haemor- 
rhaginous  transudations.  In  these  and  other  cases  meta- 
morphosed elements  of  the  blood  are  found  scattered 
through  the  brain  cortex  and  sometimes  in  the  white  sub- 
stance. In  those  cases  which  the  writer  has  himself  ex- 
amined post  mortem  he  has  found  nothing;];  beyond  a  very 
slight  degree  of  cortical  hypersemia,  and  one  not  differing 
from  the  hypersemia  found  in  sane  persons  dying  with  cer- 
tain lung  diseases,  and  not  equalling  that  hyperaemia  some- 
times found  in  the  brains  of  those  dying  of  fevers.  In 
not  a  single  accurately  studied  case,  reported  by  trust- 
worthy observers,  has  a  characteristic  lesion  of  the  essen- 
tial mental  apparatus  been  found,  nor  has  any  doubtful  ap- 
pearance of  any  kind  been  discovered  that  has  not  been 
found,  in  lesser  degree,  in  sane  persons  also.  The  latest 
and  most  thorough  writer  §  on  mania  concludes  his  chap- 
ter on  pathological  anatomy,  naturally  the  most  meagre  in 
his  work,   with  these  words:  "  From   all  this  I   draw  the 


*  Krafft-Ebing,  Lehrbuch,  I.  p.  11.  This  quotation  is  well  supple- 
mented by  Schiile  {Seq.). 

f  Calmeil,  Article  Manie,  Diet.  deMed.,  etc.;  Meynert,  Psych.  Central- 
blatt,  1871;  Westphal,  Charite-Annalen,  I.,  1876:  Ripping,  Die  Geistes- 
storungen  der  Schwangeren,  Wochnerinnen  und  Saugenden.  Stuttgart, 
1877;  Mendel,  Die  Manie,  1881. 

\  The  writer  excepts  from  these  remarks  his  findings  in  a  single  case 
of  delirium  grave,  a  condition  which  he  does  not  agree  with  Mendel  in 
classifying  under  the  head  of  "  Mania,"  properly  so  called. 

S  Mendel :   Die  Manie  18S1. 


98  INSANITY. 

conclusion  that  mania  is  a  disease,  whose  patho-anatomical 
basis  we  have  thus  far  not  been  able  to  discover  in  the 
brain.  In  this  light  we  must  look  upon  it  as  a  functional 
disorder,  because  those  alterations  (of  the  brain)  which 
must  be  supposed  to  determine  the  disturbance  of  the  cere- 
bral functions  are  undemonstrable  with  our  present  means 
of  investigation." 

When  we  recollect  that  only  from  two  to  five  per  cent  of 
maniacs  die,  and  that,  consequently,  chiefly  those  subjects 
reach  the  post-mortem  table  in  whom,  either  through  com- 
plications or  an  intensification  of  the  maniacal  excitement 
to  the  degree  of  maniacal  exhaustion,  the  brain  disturbance 
must  be  assumed  to  have  reached  a  far  higher  pitch  than  in 
the  ninety-five  or  more  percent  surviving;  when  we  bear  in 
mind  that  Esquirol,  Griesinger,  and  others  consider  the 
possibility  of  and  cite  cases  to  prove  the  causation  of 
maniacal  symptoms  by  processes  associated  with  anaemia 
instead  of  hypera;mia  of  tlie  brain,  it  must  be  clear  that  the 
evidence  concerning  the  tangible  signs  of  a  form  of  insan- 
ity comprising  a  large  proportion  of  asylum  admissions  is 
fragmentary  and  inconclusive  where  it  is  not  entirely  nega- 
tive. 

Nearly  the  same  remarks  apply  to  simple  melancholia; 
the  most  complete  series  of  investigations — that  of  Mey- 
nert — yielded  no  other  result  than  the  conclusion  that  cor- 
tical and  meningeal  hypersemia  are  far  rarer  and  lymph- 
space  dilatation  more  frequent  here  than  in  mania,  and  on 
this  he  was  enabled  to  base  some  ingenious  hypotheses. 
The  writer's  own  investigations,  including  the  examination 
of  several  melancholiacs  dying  in  and  out  of  asylums,  have 
satisfied  him  that,  with  our  present  means  of  investigation, 
a  change  in  the  essential  nervous  structures  is  not  demon- 
strable.* Even  in  melancholiacs  whose  symptoms  have 
reached  the  degree  of  atonic  stupor,  the  morbid  appear- 
ances, such  as  oedema  of  the  membranes  and  pallor  of  the 
cortex,  are  possibly  referable  to  starvation  from  prolonged 
refusal  of  food,  and  to  the  lung  diseases  which  are  so  fre- 
quently concomitant  to  this  affection.  These  differso  little 
from  the  similar  appearances  found  in  ordinary  hospital 
patients  dying  from  inanition  and  phthisis,  that  we  can 
only  conclude,  as  in  the  case  of  maniacs  who  recover,  that 
the  larger  proportion  of  melancholiacs  exiiibit  nothing  posi- 

*  Katatonia  is  not  included  here. 


THE    MORBID   ANATOMY    OF   INSANITY.  99 

lively  demonstrating  their  disease  in  the  brain  structure. 
How  uncertain  the  anatomical  basis  is  in  those  forms  of  in- 
sanity for  which  the  writer  defends  the  retaining  of  the 
term  "  monomania,"  *  forms  comprising  as  mucii  as  twenty- 
five  per  cent  of  some  asylum  admissions,  cannot  be  better 
illustrated  than  by  a  citation  from  the  author  of  the  article 
"  Insanity,"  in  Ziemssen's  Cyclopaedia.  "The  pathological 
anatomy  of  monomania  is  the  most  meagre  chapter  of  our 
generally  extremely  moderate  knowledge  of  psychological 
morbid  anatomy.  In  the  case  of  some  'original  monoma- 
niacs' {Origindr  Verriickte)  Sander  and  Muhr  have  called 
attention  to  interesting  anomalies  of  the  skull  and  brain, 
in  part  congenital  and  in  part  acquired  in  early  infancy. 
But,  for  the  great  majority  of  those  later  attacked  by  mono- 
mania, no  gateway  promising  to  lead  with  any  certainty  to 
the  laboratory  of  these  serious  and  deeply  grasping  changes, 
which  attack  the  very  essence  of  the  ego,  has  been  so  far 
discovered." 

In  epileptic  insanity,  sometimes  comprising  eight  per 
cent  of  asylum  admissions,  no  morbid  appearances  can  be 
found  in  a  large  number  of  recent  cases,  and  those  found, 
such  as  asymmetry  of  the  brain  and  skull,  rather  indicate 
the  frequently  hereditary  and  congenital  origin  of  the  dis- 
order than  that  they  explain  the  exact  basis  of  the  insanity. 
Even  in  advanced  cases  of  epileptic  insanity  it  is  not  the 
exception  to  find  but  very  slight  and  doubtful  indications 
of  that  disorder /^j-/  mortem.  In  some  instances,  atrophy  of 
the  brain,  vascular  kinking,  cystic  degeneration  of  the  cor- 
tex, and  extreme  pigmentation  of  the  nerve-cells,  particu- 
larly in  the  medulla,  are  found.  With  chronic  secondary 
insanity,  dementia,  and  other  terminal  deteriorations,  the 
brain  is  more  constantly  diseased;  it  is  diminished  in 
weight,  the  convolutions  appear  shrunken,  the  cells  of  the 
brain-rind  wasted,  the  blood-vessels  show  the  vicious  influ- 
ence of  long-continued  disturbances  of  the  blood-supply; 
but  even  here  there  are  cases  where  the  post-mortem  evi- 
dence is  not  conclusive.  With  imbecility  and  idiocy  ana- 
tomical evidences  of  imperfect  brain  development  are  com- 
mon. Finally,  in  progressive  paresis,  or  paretic  dementia, 
the  post-mortem  record  is  exceptionally  satisfactory.  It  is 
safe  to  say  that  if,  in  a  case  where  this  disease  is  claimed  to 
have  lasted  longer  than  a  year,  certain  changes  in  the  nerve- 

*See  Monomania. 


lOO  INSANITY. 

centres  are  not  found,  the  justice  of  the  claim  is  seriously 
impaired. 

Summarizing  the  teachings  of  the  master-minds  in  pathol- 
ogy, of  reliable  observers  generally,  and  the  writer's  own 
experience,  he  considers  himself  justified  in  saying  that 
positive  and  indisputable  evidence  of  insanity  cannot  be 
found  in  more  than  thirty  per  cent  of  the  insane;  that  in 
another  thirty  per  cent  slight  changes  are  found,  not  differ- 
ing in  character,  though  perhaps  in  extent,  from  what  is 
observed  in  some  sane  subjects;  while,  in  the  remainder, 
there  is  no  visible  deviation  from  the  normal  standard  of 
any  kind.  To  be  more  specific  in  regard  to  the  various 
forms  of  insanity,  the  likelihood  of  finding  characteristic 
structural  changes  in  the  insane  brain  may  be  represented 
as  follows:  In  true  and  recent  mania  that  likelihood  is  as 
5  :  loo;  in  acute  melancholia  it  is  almost  zero;  in  epileptic 
insanity  it  is  as  20  :  100;  in  monomania  it  is  as  5  :  100;  in 
the  terminal  states,  it  is  as  60:  100;  in  imbecility  and  idiocy, 
as  80  :  100;  in  paretic  dementia  it  reaches  the  figure 
99+  :  100,  and  here  alone  and  in  insanity  with  organic  dis- 
eases does  the  autopsy  approximate  the  dignity,  from  every 
point  of  view,  of  a  scientifically  positive  test.  The  writer 
does  not  give  these  figures  as  exact,  but  only  to  indicate  as 
nearly  as  figures  derived  from  a  comparison  of  authorities 
and  experience  can,  the  degree  of  certainty  with  which  a 
post-mortem  finding  may  be  anticipated,  and  the  extent  to 
which  it  may  serve  as  the  test  of  an  opinion. 

The  various  genuine  changes  which  are  found  more  or 
less  constantly  associated  with  the  ordinary  forms  of  in- 
sanity may  be  considered  together.  There  is  one  form  of 
insanity,  paretic  dementia,  which  is  a  pathological  entity; 
its  morbid  anatomy  is  as  well  known  as  that  of  other 
organic  nervous  diseases,  and  the  relation  between  its  mor- 
bid changes  and  the  symptoms  thereon  depending  is  suffi- 
ciently constant  to  justify  the  establishment  of  a  patho- 
genesis of  this  malady.  For  these  reasons  the  morbid 
anatomy  of  this  form  of  insanity  will  be  separately  con- 
sidered; and  the  subjoined  remarks  are  not  intended  to 
cover  the  pathology  of  that  disorder,  nor  of  those  rarer 
forms  of  insanity  whose  anatomical  features  require  to  be 
specially  referred  to  in  the  second  part  of  this  manual 
where  these  forms  are  separately  considered. 

The  greatest  interest  attaches  to  the  changes  in  the  essen- 
tial apparatus  of  thought  and  action — namely,  the   brain; 


THE    MORBID    ANATOMY   OF   INSANITY.  lOI 

and  in  this  organ  it  is  particularly  the  cortex  or  brain-rind 
of  the  cerebral  hemispheres  which  has  been  made  the  sub- 
ject of  the  closest  study.  It  is  in  the  nerve-cells  of  this 
cortex  that  the  individual  elements  of  thought  and  action 
are  supposed  to  be  seated,  being  represented  by  force  oscil- 
lations in  their  complex  protoplasm;  and  it  is  in  the  nerve 
fibrillae  connecting  these  cells,  and  in  the  coarse  fibre- 
bundles  associating  neighboring  as  well  as  distant  cortical 
areas  that  the  physiologist  is  compelled  to  locate  the  cor- 
relating and  co-ordinating  mental  faculties,  in  short  those 
without  which  no  logical  comparison  nor  conclusion  can  be 
made.*  From  all  this  it  is  evident  that  a  rational  psycho- 
pathology  is  really  nothing  more  nor  less  than  a  branch  of 
general  cerebral  pathology;  or,  as  Meynert  expressed  it, 
that  the  pathology  of  insanity  is  merely  a  chapter  in  the 
morbid  anatomy  of  the  fore-brain. f 

Changes  in  the  Cerebral  Tissues. — In  the  majority  of 
the  recent  cases  of  insanity  no  coarse  change  of  the  cortex 
can  be  detected  which  is  not  dependent  on  the  degree  of 
vascular  injection.  It  is  due  to  the  arrangement  of  the 
cortical  capillaries  that  an  unusual  degree  of  injection  mark- 
ing itself  in  the  deep  and  superficial  cortical  plexuses  ob- 
literates the  normal  lamination  of  the  cortex  to  the  naked 
e)''e.  On  hardening  specimens  of  such  a  cortex  the  lami- 
nation returns,  and  under  the  microscope   the  distinctness 

*  It  has  been  not  inaptly  said  that  the  mental  co-ordinations  acquired 
in  the  course  of  a  higher  civilization  are  the  ones  which  are  most  often 
defective  in  the  lunatic.  It  may  be  presumed  that  the  sub-cortical  nerve 
tracts  which  are  the  latest  in  attaining  their  full  development,  and  which 
indeed  have  not  attained  that  development  at  birth,  are  the  essential 
mediators  of  those  intricate  co-ordinations.  As  we  proceed  from  the 
lower  mammalia  to  the  higher,  and  as  we  follow  up  the  successive  stages 
of  the  hum.an  embryo  and  foetus,  we  find  that  the  isolation  of  conducting 
tracts,  and  the  related  overgrowth  and  emancipation  of  the  associating 
systems,  appears  to  be  the  ideal  aim  of  the  highest  development.  What 
more  imperative  conclusion  is  there  in  the  entire  field  of  mental  science 
than  that  the  source  of  the  more  complex  disturbances  of  the  mind  must 
be  sought  for  right  here? 

f  This  term  has  been  erroneously  used  by  some  writers  as  a  synonym 
for  the  frontal  lobes.  In  reality  it  is  an  English  rendering  of  the  German 
term  "  Vorderhirn,"  or  the  Latin  equivalent  "  Prosencephalon,"  and  in 
its  widest  sense  includes  the  cerebral  hemispheres  and  the  thalami. 
One  of  our  best  comparative  anatomists.  Wilder,  thinks  the  vernacular 
term  "  fore-brain"  unnecessary.  It  is,  however,  a  convenient  one  for  the 
alienist,  as,  in  the  sense  here  set  forth,  it  is  the  nearest  anatomical  equiv- 
alent for  the  physiological  conception  of  the  "  organ  of  the  mind,"  which 
ought — provisionally  at  least — to  include  the  thalami. 


102  INSANITY. 

of  the  cells  and  the  layers  in  which  they  are  arranged  is 
found  to  be  as  great  as  in  the  normal  brain,  thus  showing 
that  the  obliteration  of  the  coarse  lamination  is  only  a 
seeming  one  and  has  no  histological  significance.  The 
essential  cortical  structure  is  similarly  unaffected  by  the 
extreme  anaemia  found  in  melancholia  and  stupor.  But  in 
cases  in  which  a  transition  to  dementia  is  likely  and  which 
reach  the  autopsy  table,  through  some  inter-current  dis- 
ease, the  perivascular  and  periganglionic  spaces,  which  are 
supposed  to  appertain  to  the  lymphatic  system  of  the 
brain,  are  found  to  be  unusually  large.  This  phenome- 
non is  probably  the  expression  of  a  retarded  lymph  out 
flow.  In  some  extreme  cases  an  accumulation  of  lymph- 
bodies  in  and  near  these  spaces  occurs;  this  appearance 
was  noted  in  a  pronounced  degree  by  the  writer  in  the 
single  case  of  katatonia,  examined  by  him  post  mortem. 
It  is  susceptible  of  the  same  interpretation  as  the  perivas- 
cular dilatation  with  which  it  is  usually  connected. 

In  chronic  insanity  a  number  of  changes  are  noted  which 
may  be  regarded  as  partly  the  secondary  results  of  the 
vascular  lesions,  to  be  later  considered,  partly  as  the  anatom- 
ical expression  of  a  premature  senescence  of  the  nervous 
tissues.  The  closer  the  insanity  approaches  the  degree  of 
a  dementia  the  more  apt  are  these  changes  to  be  marked 
and  characteristic.  They  are  hence  prominent  and  fre- 
quent in  that  secondary  form  of  insanity  which  is  common- 
ly called  chronic  mania  (which  the  writer  proposes  to  term 
secondary  or  chronic  confusional  insanity),  and  most  promi- 
nent and  frequent  in  dementia;  while  they  are  far  less  fre- 
quent in  monomania,  though  they  are  found  even  here  as 
an  expression  of  the  partial  deterioration  observed  in  this 
affection.  The  periodical  and  epileptic  forms  of  insanity, 
marked  as  they  are  by  recurring  vaso-motor  crises,  are 
often  accompanied  by  changes  showing  the  destructive  in- 
fluence of  the  latter. 

The  various  vicissitudes  to  which  the  healthy  brain  is  ex- 
posed, its  physiological  hyperaemias,  and  probably  also 
the  febrile  disorders  and  emotional  strain  through  which 
its  bearer  has  to  pass,  register  their  influence  in  pigmenta- 
tion of  the  nerve-cells,  in  accumulations  of  blood  pigment 
and  granular  material  in  theadventitia  of  the  blood-vessels, 
and  these  changes,  gradually  intensifying  with  age,  lead  to 
the  vascular  degeneration  and  nerve-cell  atrophy  some- 
times found   in  advanced  life.     The  influence  of  the  more 


THE    MORBID   ANATOMY   OF   INSANITY.  I03 

intense  vaso-motor  cataclasms  of  insanity,  and  the  greater 
functional  abuse  of  the  organ  of  the  mind  in  this  disorder 
lead  to  a  correspondingly  more  intense  and  more  rapid 
tissue  deterioration  in  the  insane.  It  is  for  this  reason  that 
the  lesions  of  the  forms  of  chronic  mental  disorder  here  re- 
ferred to  do  not  generally  differ  in  kind  from  certain  ap- 
pearances found  in  most  healthy  persons  who  have  passed 
the  twentieth  year,  though  they  may  differ  greatly  in 
degree. 

In  extreme  cases  of  chronic  insanity,  particularh'  where 
marked  mental  deterioration  has  permanently  set  in, 
atrophy  of  the  essential  nerve  elements  is  found.  To  the 
naked  eye  this  is  made  manifest  in  diminution  in  size  of 
the  entire  brain,  in  enlargement  of  the  ventricles,  in  shrink- 
ing of  the  convolutions,  and  in  consequent  gaping  of  the 
sulci.*  By  the  balance  it  is  made  evident  as  a  general  de- 
crease in  weight,  particularly  of  the  cerebral  hemispheres. 
With  the  scalpel  it  is  recognizable  by  a  greater  firmness  of 
the  tissues,  due  to  the  relative  preponderance  of  the  con- 
nective over  the  strictly  nervous  substances.  Finally,  the- 
microscope  shows  that  the  nerve-cells  are  diminished  in 
number,  and  either  are  shrunken  in  all  dimensions  or  pre- 
sent appearances  of  passing  through  the  successive  stages 
of  destructive  degeneration.  More  or  less  change  is  observ- 
able in  the  white  substance:  gaps  form  more  readily  in 
hardening  than  in  the  healthy  brain,  showing  that  there  is 
a  rarefication  of  tissues;  the  myelin  is  not  as  well  marked, 
and  various  fine  shades  of  color  are  noted  which  are  not 
observed  in  the  the  healthy  brain;  strands  of  nerve  fibres 
are  seen  which  have  a  grayish  or  brownish  tinge,  and  others 
which  have  a  dead-white  color,  and  these  are  usually  found 
to  be  connected  with  those  cortical  fields  where  atrophy  is 
most  marked.  These  changes  in  color  are  not  the  ex- 
pression of  a  genuine  sclerosis,  but  of  some  finer  disease 
process  whose  real  nature  has  yet  to  be  determined. 

Changes  in  the  Nerve-cells. — The  more  violent  the 
manifestations  of  the  psychoses  were  during  life,  the  more 
likely  are  the  nerve-cells  to  show  the  effect  of  rapidly  pro- 
duced nutritive  disturbance.  Their  protoplasm  in  that  case 
is  cloudy,  their   processes  stain  poorly,  and  the  nucleus  is 

*It  is  due  to  this  fact  that  the  atrophic  brains  of  the  chronic  insane 
exhibit  the  typical  sulci  much  more  satisfactorily  for  the  beginner  than 
healthy  brains. 


I04  INSANITY. 

ill  marked.  But  it  is  unusual  to  find  this  change  in  other 
mental  disorders  than  acute  delirium,  and  in  those  following 
fever  and  accompanying  meningitis.  In  acute  mania  and 
melancholia  the  nerve-cells  are  perfectly  healthy  to  the  eye, 
and  typical  specimens  for  anatomical  demonstration  have 
been  obtained  by  the  writer  from  the  brains  of  those  dying 
of  either  of  these  disorders. 

In  chronic  insanity  of  long  standing  there  are  particularly 
two  series  of  changes  which  engage  the  attention  of  the 
pathologist.  The  first  seems  to  be  a  rather  J>assh'e  atrophy; 
the  cells  appear  to  be  diminished  only  in  size,  the  smaller 
nerve-cells  are  indistinct,  and  the  nerve  processes  seem  to  be 
fewer.  In  extreme  degrees  of  this  change  some  of  the  cells 
scarcely  take  carmine  staining  at  all,  although  side  by  side 
with  them  are  found  others  showing  the  normal  degree  of 
imbibition  of  the  staining  fluid.  It  has  even  been  claimed 
by  Forster  and  others  that  calcification  occurs  under  similar 
circumstances.  All  this  suggests  that  a  gradual  deteriora- 
tion from  the  highh'  protoplasmic  character  of  the  nerve- 
cells  has  taken  place.  This  condition  is  found  in  that 
apathetic  dementia  which  follows  melancholia  and  stupor- 
ous insanity. 

The  second  series  of  changes  is  of  more  common  occur- 
rence. It  is  an  intensification  of  that  normal  involution  of 
the  nerve-cell  which  takes  place  with  advancing  years. 
While  the  pigmentation  of  the  nerve-cells  of  the  healthy 
cortex  is  in  middle  life  limited  to  the  larger  pyramidal  cells, 
it  extends  to  the  smaller  ones  in  chronic  insanity.  While 
the  pigment  granules  of  the  normal  brain-cell  are  exceed- 
ingly fine,  and  do  not  appear  to  affect  the  fibrillar}^  struc- 
tures of  the  cell  protoplasm  ;  in  the  diseased  condition  the 
pigment  is  in  clumps,  consisting  of  coarse  granules,  ob- 
jj^tUf  scuring  or  crowding  among  the  nucleus,  and  obliterating 
/r  the  fibrillary  structure  referred  to.  This  change  seems  to 
produce  different  results  when  it  affects  the  smaller  nerve- 
cells.  These  are  often  converted  into  an  apparently  homo- 
geneous yellow  substance,  without  any  alteration  in  shape  ; 
the  nucleus  shares  in  this  change  in  a  lesser  degree,  but 
does  not  lose  its  outline  or  distinctness.  Inasmuch  as  with 
this  class  of  changes  it  is  common  to  find  morbid  states  of  the 
blood-vessels,  it  is  reasonable  to  regard  the  recorded  pig- 
mentary-granular change  of  the  nerve-cells  as  the  result  of 
active  nutritive  disturbance.    The  final  phase  of  this  change. 


THE    MORBID   ANATOMY   OF   INSANITY.  105 

a  destruction  of  the  nerve-cell,*  is  noted  in  the  larger  pyra- 
mids in  extreme  dementia,  just  as  it  is  a  regular  occurrence 
in  advanced  senility.  It  manifests  itself  by  the  obscuration 
or  disappearance  of  the  nucleus,  and  the  separation  and 
disappearance  of  the  cell  processes.  Finally,  nothing  but 
an  irregular  mass  of  granules  and  pigment  serves  to  mark 
the  former  site  of  the  ganglionic  element.  Observers  have 
spoken  of  this  process  as  a  fatty  degeneration  or  a  fatty 
pigmentary  change.  But  micro-chemistry,  while  it  has  not 
yet  revealed  the  exact  nature  of  these  bodies,  has  demon- 
strated that  they  are  not  of  a  fatty  nature.  And  it  may  be 
a  proper  place  to  insist  here  that  the  current  statement, 
repeated  in  more  than  one  text-book  on  physiology,  and 
copied  into  several  treatises  on  insanity,  that  the  active 
ph)''siological  ingredient  in  the  brain  is  a  "  phosphorized  oil 
or  fat,"  is  absolutely  erroneous.  The  healthy  brain  con- 
tains no  true  fat,  and  the  various  reports  of  fatty  degenera- 
tion of  the  diseased  brain  will  have  to  be  very  carefully 
sifted  in  the  light  of  modern  chemistry  before  they  can  be 
accepted.  The  recorded  proofs  of  fatty  degeneration  seem 
to  rest  on  the  reaction  of  the  alleged  fatty  material  to  ether. 
But  ether  affects  other  substances  than  the  fats  in  a  similar 
way. 

Changes  in  the  Neuroglia. — The  so-called  nuclei  of  the 
neuroglia,  small  round  bodies  which  are  derived  from  the 
formed  elements  of  the  blood,  are  frequently  increased  in 
number  in  insanity  of  long  standing,  particularly  when  it 
is  accompanied  by  excitement.  Unfortunately  not  enough 
is  known  of  the  true  nature  of  the  neuroglia  to  enable 
pathologists  to  explain  a  familiar  change,  common  in  ad- 
vanced deterioration.  It  is  remarked  that  the  longer  a 
specimen  of  the  brain  cortex  is  hardened,  especially  if  it  be 
hardened  in  chromic  acid  or  its  salts,  the  more  decided  be- 
comes a  certain  fibrinous  texture  of  the  neuroglia.  It  is  not 
determined  thus  far  whether  this  network  of  fibrils  is  of  a 
nervous  or  a  connective-tissue  character  ;  it  certainly  is  the 
expression  of  a  normal  structure.  The  longer  the  harden- 
ing processes  continue  the  more  does  this  network  con- 
tract, its  meshes  then  widen,  and  numerous  small  roundish 


*  It  is  customary  to  speak  of  nerve  "cells,"  although  it  should  be 
borne  in  mind  that,  in  the  strict  histological  sense,  the  ganglionic  bodies 
of  the  cortex  are  not  cells  in  the  common  acceptation  of  the  term. 


I06  INSANITY. 

or  oval  cavities  appear.  Evidently  the  hardening  process 
is  accompanied  by  the  solution  and  removal  of  some  sub- 
stance and  the  condensation  of  the  fibrillar  network.  Now 
what  hardening  does  after  a  long  period  in  a  healthy  brain 
that  will  it  do  in  a  much  shorter  time  in  the  brains  of  some 
of  the  chronic  insane,  particularly  in  senile  dementia.  In- 
deed, a  similar  condition  'may  be  here  determined  in  the 
fresh  tissues,  and  is,  therefore,  undoubtedly  pathological. 

Changes  in  the  Blood-vessels. — The  cerebral  cortex  is 
one  of  the  most  vascular  tissues  in  the  body.  Among 
parenchymatous  tissues  it  is  exceeded  in  vascularit}'^  only 
by  the  blood  glands.  It  is,  consequently,  but  natural  that 
some  of  the  more  important  pathological  changes  of  insanity 
should  be  found  to  commence  in  the  intricate  nutritive 
plexus  of  the  cortical  blood-vessels.  The  changes  in  blood- 
vessels may  affect  the  structure  of  the  blood-vessel  itself,  its 
contour,  and  its  appendages. 

Structural  Changes  of  the  Vascular  I  Vail  Proper. — Prolifera- 
tion of  the  nuclei  in  the  vascular  tissues  and  a  fine  granular  or 
a  colloid  change  of  the  muscular  coat  are  common  appear- 
ances. The  term  "  colloid  "  here  used  has  reference  only 
to  the  optical  appearance  of  the  morbid  deposit;  it  is  not 
intimated  that  the  latter  has  the  composition  of  what  is  or- 
dinarily called  colloid  substance.  It  is  also  to  be  insisted 
on  here,  that  the  so-called  colloid  transformation  of  entire 
blood-vessels  reported  by  some  observers  is  due  to  the 
methods  of  hardening  employed,  and  is  therefore  not  a  bo?ia- 
fide  lesion.  A  general  sclerosis  of  all  the  cortical  vessels 
is  a  common  condition  in  advanced  insanity,  and  may  be 
regarded  as  a  sequel  of  the  nuclear  proliferation  alluded  to. 
In  extreme  cases  this  sclerosis  reaches  the  degree  of  a 
fibrous  transformation,  the  nuclei,  previously  abundant, 
now  disappear  as  such,  and  the  whole  vessel  may  degene- 
rate into  a  fibrous  filament,  perhaps  even  devoid  of  a  lumen. 

Changes  in  the  Adventitia. — Much  controversy  has  grown 
out  of  the  claim  that  there  are  two  lymph  spaces  around  the 
cortical  blood-vessels,  one  which  is  sub-adventitial  and  one 
which  is  extra-adventitial.  There  seems  to  be  no  doubt 
possible  that  while  the  space  of  His — that  is,  the  perivascu- 
lar space — does  not  exist  in  health,  it  certainly  exists  in  dis- 
ease, probably  as  a  dilatation  around  the  adventitia,  compen- 
sating for  the  impeded  lymph  outflow  through  the  natural 
sub-adventitial  channel.  This  dilatation  is  accompanied  by 
a  dilatation    of  the  peri-ganglionic  spaces,  and  this  latter 


THE    MORBID   ANATOMY   OF   INSANITY.  lO/ 

reaches  so  extreme  a  degree,  not  only  in  paretic  dementia 
(where  it  is  most  common),  but  also  in  advanced  epileptic 
and  periodical  insanity,  that  the  spaces  resulting  sometimes 
become  visible  to  the  naked  eye.  (See  Fig.  2).  This  is  the 
origin  of  the  so-called  e'tat  crible  of  the  cortex,  which  will 
be  described  in  detail  in  the  chapter  on  Paretic  Dementia. 

The  most  constant  morbid  appearance  in  insanity  is  the 
deposit  of  granular  and  pigmentary  material  in  the  adven- 
titia.  This  is  to  be  regarded  as  the  result  of  repeated  flux- 
ionary  states,  and  is  probably  one  of  the  earliest  changes 
in  progressive  insanity,  as  indeed  it  is  but  an  intensification 
of  the  same  appearance,  found  on  a  greatly  reduced  scale, 
in  every  healthy  adult.  The  granular  pigment,  usually  of 
a  yellowish,  and  rarely  of  a  decidedly  brownish  tinge,  is 
found  accumulated  in  scattered  foci  or  in  larger  patches 
along  the  course  of  the  vessel,  and  particularly  at  the  vas- 
cular bifurcations.  While  the  arterioles  which  are  visible 
to  the  naked  eye  show  this  change  very  markedly,  the 
smaller  vessels  may  be  quite  free  from  it. 

In  advanced  insanity,  particularly  of  the  epileptic  and 
periodical  types,  and  in  clironic  confusional  insanity  with 
excitement,  profound  changes  in  the  direction  and  shape 
of  the  blood-vessels  are  frequent.  The  blood-vessels,  which 
in  a  healthy  state  are  straight  or  slightly  undulating,  in 
these  conditions  become  tortuous,  twisted,  and  redoubled 
on  themselves,  so  that  in  exceptional  instances,  instead  of  a 
straight  vascular  tube,  as  in  health,  we  have  a  pseudo-glo- 
merular  coil.  The  calibre  of  the  blood-vessel  is  also  affect- 
ed; it  is  not  equal,  but  irregularly  dilated  and  constricted. 
Sometimes  the  dilatation  resembles  a  minute  fusiform  aneu- 
rism, and  an  almost  varicose  condition  is  occasionally  ob- 
served to  accompany  this.  But  in  not  a  single  autopsy  has 
the  writer  observed  that  true  miliar}'  aneurismal  condition 
which  has  been  claimed  to  be  so  common  in  insanity.  He 
questions  whether,  in  view  of  the  fact  that  miliary  aneu- 
risms have  been  found  by  Virchow  in  healthy  subjects,  and 
unaccompanied  l^y  an)''  structural  change,  those  found  in 
the  insane  should  be  regarded  as  more  than  accidental  or 
collateral  conditions. 

It  is  a  natural  result  of  the  weakening  of  the  vascular 
walls,  and  the  diminished  resistance  of  the  wasted  sur- 
rounding tissues,  as  well  as  of  the  frequent  fiuxionary  epi- 
sodes of  certain  forms  of  insanity,  that  minute  haemor- 
rhaofes  and  their  traces    are    sometimes    observed   in   the 


I08  INSANITY. 

cortex  of  the  insane.  It  is  also  not  difficult  to  bring  the 
changes  in  the  neuroglia  and  nerve-cells  previously  noted, 
into  relation  with  the  impeded  transudation  of  nutritive 
material,  through  degenerated  vascular  tubes,  and  the  re- 
tarded removal  of  effete  products  through  the  overstrained 
and  blocked-up  lymph  passages  of  the  degenerating  brain. 

The  observations  made  concerning  anaemia  and  hyper- 
aemia  of  the  brain  after  death,  if  we  exclude  paretic  de- 
mentia and  acute  delirium,  have  very  little  value.  The 
real  condition  as  it  was  during  life  is  generally  obliterated 
by  intercurrent  disease,  or  by  the  mortuary  changes.  In  a 
body  which  has  been  placed  on  the  table  with  the  face 
down,  the  frontal  lobes  may  be  found  to  be  more  injected 
than  the  occipital;  if  it  is  placed  on  its  back,  the  reverse 
will  generally  be  found  to  be  the  case.  All  these  consider- 
ations show  how  uncertain  the  interpretation  of  so-called 
congestive  or  anaemic  conditions  must  be,  and  how  little 
value  can  be  attached  to  the  observation  of  a  number  of 
authors,  who  claim  that  in  maniacal  conditions  the  brain 
is  found  hypersemic,  and  in  melancholiac  ones  anaemic,  on 
the  strength  of  the  degree  of  injection  found  post-wortem. 
The  condition  of  the  brain  as  it  was  /////-a  v/ta///  can  be  bet- 
ter determined  by  an  examination,  during  life,  of  the  vaso- 
motor system  with  our  instruments  of  precision;  and  after 
death,  by  the  morphological  characters  of  the  blood-vessels 
and  the  lymph  spaces  observed  under  the  microscope.  Di- 
lated lymph  spaces  signify  obstruction  to  the  lymphatic 
outflow;  tortuous  blood-vessels  indicate  a  weakening  of 
their  coats  through  repeated  overstrain.  The  former  con- 
dition predominates  with  the  atonic  forms  of  insanity,  the 
latter  with  those  marked  by  excitement. 

Weight  of  the  Brain. —  It  may  be  stated  to  be  a  gen- 
eral rule,  that  in  chronic  insanity  generally  the  brain  loses 
slightly  in  weight,  and  that  the  loss  in  weight  increases 
with  advancing  deterioration,  until  in  dementia  it  becomes 
considerable.  In  acute  insanity  and  in  early  monomania 
there  is  often  no  perceptible  difference  from  the  healthy 
standard.  Numerous  brains  may  be  found  in  the  dead- 
house  of  an  asylum  exceeding  in  weight  those  found  in  the 
hospital  dead-house,  though  the  average  is  lower  in  the  for- 
mer. In  estimating  the  bearing  of  the  loss  in  weight  of  the 
brain  in  insanity,  the  influence  of  intercurrent  somatic  af- 
fections must  be  also  taken  into  account;  for  in  ordinary 
chronic   diseases  without    insanity  a  considerable    loss  in 


THE    MORBID   ANATOMY   OF   INSANITY.  IO9 

brain  weight  is  often  noted.  Pfleger  has  found  that  the 
loss  in  weight  in  the  sane  dying  of  chronic  diseases  is  about 
eight  per  cent,  while  in  the  insane  the  average  weight  is  ten 
per  cent  below  the  normal  average. 

The  same  observer,  in  his  very  careful  measurements, 
found  that  the  male  brain  suffers  a  greater  loss  in  weight  in 
insanity  than  the  female  brain,  while  Meynert  arrived  at  the 
opposite  conclusion.  It  seems  to  the  writer  that  Pfieger's 
statement  may  have  been  made  without  reference  to  the 
original  weight  of  the  organ  in  the  insane  of  the  two  sexes. 
In  man)^  cases,  particularly  where  there  is  a  constitutional 
taint,  there  are  evidences  pointing  to  a  primary  deficiency 
in  brain  development.  Inasmuch  as  the  male  brain  is  nor- 
mally larger  than  the  female  brain,  both  absolutely  and  rel- 
atively, and  would  presumably  suffer  more  in  congenital 
deficiency,  it  is  apparent  that  a  serious  source  of  error  has 
been  overlooked  by  the  Austrian  pathologist. 

Neither  the  chemical  anal3^sis  nor  the  measurement  of 
the  specific  gravity  of  the  insane  brain  has  led  to  results 
of  sufficient  importance  to  detain  us  here. 

Changes  in  the  Brain  Membranes. — In  chronic  insan- 
ity the  membranes  frequently  show  a  morbid  condition. 
It  must  be  borne  in  mind,  however,  that  many  of  the  mem- 
branous changes  found  in  insanity  are  also  found  in  the  or- 
dinary hospital  population;  while,  on  the  other  hand,  brains 
may  be  found  in  persons  who  have  been  insane  for  a  score 
of  years,  particularly  among  monomaniacs,  whose  mem- 
branes and  tissues  generally,  may  present  a  picture  of  ideal 
health  ! 

Inflammation  of  the  dura  is  rare  in  simple  insanity,  but 
is  common  in  alcoholic,  syphilitic,  and  paretic  dementia. 
Its  more  characteristic  features,  as  well  as  the  morbid  an- 
atomy of  the  meningeal  blood  cysts,  which  are  by  some 
considered  to  be  the  result  of  pachymeningitis,  need  not 
be  detailed  here,  as  they  will  come  up  for  consideration  in 
the  analysis  of  the  morbid  anatomy  of  the  disorders  men- 
tioned. 

A  very  familiar  appearance  to  the  alienist  pathologist  is 
a  milky-white  opacity  of  the  arachnoid  which  may  affect 
the  entire  expanse  of  that  structure.  It  is  found  in  a 
large  number  of  the  chronic  insane,  and  is  usually  asso- 
ciated with  epithelial  granulations  of  the  pia,  and  increase 
in  the  size  and  number  of  the  Pacchionian  bodies.  All 
these  conditions  indicate  the  existence  of  long-continued 


no  INSANITY. 

vascular  strain,  with  consequent  exudation  of  formed  ele- 
ments of  the  blood,  causing  cellular  infiltration  and  thick- 
ening of  the  arachnoid  lamellae  on  the  one  hand,  and  en- 
largement of  the  "  safety  diverticula"  of  the  great  cerebral 
veins,  as  which  the  Pacchionian  bodies  are  to  be  regarded, 
on  the  other.  All  these  conditions,  however,  occur  in  per- 
sons who  never  have  been  insane,  and  it  cannot  be  main- 
tained that  they  in  any  way  demonstrate  the  existence  of 
insanity,  though  where  found  it  is  justifiable  to  bring  these 
morbid  appearances  into  relation  with  the  mental  disorder, 
inasmuch  as  far  more  numerous  and  intense  examples  of 
these  changes  are  found  in  the  insane  than  in  the  sane 
population.  Even  in  the  latter  group,  those  showing  any 
considerable  degree  of  these  changes  are  generally  persons 
who  have  had  syphilis,  rheumatism,  gout,  been  addicted 
to  alcoholic  excesses,  or  have  suffered  from  exhausting 
chronic  diseases. 

Although  it  is  exceptional  to  find  the  pia  adherent  to  the 
cortex  of  the  insane,  except  in  paretic  dementia,  in  insanity 
with  meningitis  or  syphilis,  and  in  insanity  following  in- 
solation, this  condition  may  be  found  in  the  terminal  period 
of  any  psychosis,  and  has  been  discovered  even  in  mono- 
mania, particularly  when  the  course  of  this  affection  has 
been  marked  by  a  number  of  ^^/t^x/- maniacal  exacerba- 
tions. There  are  sometimes  observed  in  the  insane,  par- 
ticularly in  those  whose  disorder  has  been  of  a  chronic 
character,  a  peculiar  series  of  meningeal  changes,  which 
seem  to  the  writer  to  be  interpretable  as  the  evidences  of  a 
chronic  and  subdued  inflammatory  process  which  is  not 
the  cause  of  the  insanity,  but  the  result  of  prolonged  insane 
excitement  combined  with  the  alcoholic  excesses  to  which 
this  sometimes  leads.  In  a  case  of  this  kind — an  imbecile 
with  moral  perversion  and  feeble  ideas  of  aggrandizement, 
and  who  died  with  symptoms  strongly  suggesting  the 
existence  of  an  idiopathic  organic  brain  trouble, — the  fol- 
lowing conditions  were  found  :  On  cutting  into  the  dura 
of  the  right  side  a  turbid  fluid  escaped.  It  was  impossible 
to  separate  the  dura  from  the  other  membranes  over  the 
frontal  lobe,  in  an  area  corresponding  to  two  thirds  of  its 
convexity.  Here  the  leptomeninges  and  the  dura  were 
fused  into  a  thick,  dense  common  mass  of  membranous  and 
pseudo-membranous  layers,  adherent  to  the  cortex  and 
inseparable  from  it.  On  vertical  section,  it  was  found  that 
fibrino-purulent  layers  penetrated  to  the  depth  of  the  sulci 


THE   MORBID   ANATOMY   OF   INSANITY.  Ill 

filled  the  meshes  of  the  pia  and  arachnoid,  and  merged 
with  the  thickened  and  infiltrated  dura  into  a  combined 
thickness  of  more  than  half  an  inch  at  the  focus  of  the  dis- 
ease, which  was  over  the  posterior  third  of  the  middle  and 
upper  frontal  gyri.  The  fibrino-purulent  infiltration  ex- 
tended further  backward  than  the  adhesion  of  the  men- 
inges. The  pia  shows  a  distinct  zone  of  a  yellowish  color, 
about  half  an  inch  in  extent  beyond  the  area  of  adhesion, 
and  this  zone  detached  peninsular  processes  along  the  chief 
vessels  of  the  convexity.  These,  however,  did  not  exhibit 
the  creamy-yellow  color  of  the  chief  disease  area.  On  each 
side  of  the  vessels  a  white  or  whitish-gray  streak,  varying 
from  less  than  one  to  more  than  three  millimetres  in  width, 
was  noted.  On  cutting,  this  almost  creaked  under  the  knife; 
its  consistency  could  be  best  compared  to  a  well-sized 
parchment.  In  diminishing  distinctness  this  peculiar  con- 
dition could  be  traced  as  far  back  as  the  occipital  lobe.  It 
had  every  appearance  in  these  districts  of  a  lesion  of  ancient 
date,  and  the  more  active  symptoms  of  focal  cerebral  dis- 
ease immediately  preceding  death  were  evidently  due  to 
an  intensification  of  the  lesion  in  the  way  of  an  acute  and 
local  exacerbation  ;  while  the  original  mental  deficiency 
was  attributable  to  a  congenital  defect  of  the  brain  de- 
velopment, manifesting  itself  in  gross  asymmetry  and 
atypy  not  only  of  the  cerebral  hemispheres  but  also  of  the 
peduncular  tracts,  and  was  altogether  independent  of  the  d-j 
progressive  morbid  process  discovered  after  death. 

A  number  of  morbid  appearances  are  found  in  other 
parts  of  the  body  than  the  brain  and  its  envelopes.  But 
these  are  either  concomitant  lesions  of  other  parts  of  the 
nervous  system,  such  as  the  spinal  cord,  characterizing 
certain  special  forms  of  insanity,  or  trophic  disturbances 
dependent  on  such  lesions.  In  a  comparatively  small 
number  of  instances  diseases  of  the  viscera  are  found 
which  have  an  intrinsic  signification,  and  will  hence  be 
discussed  with  the  forms  of  insanity  dependent  on  such 
diseases.  But  it  is  to  be  insisted  here  that  these  cases  are 
rather  exceptional  than  the  rule.  The  gross  lesions  fre- 
quently found  in  the  chronic  insane  are  usually  the  remote 
consequences  of  insanity  or  accidental  accompaniments, 
and  not  its  cause.  For  example,  in  hypochondriacal  luna- 
tics and  dements,  whose  psychosis  began  as  a  melancholia, 
it  is  not  rare  to  find  a  dislocation  of  the  transverse  colon, 
whose  loop  may  hang  very  low  in  the  abdominal  cavity. 


112  INSANITY. 

This  condition  is  undoubtedly  due  to  the  intestinal  inertia, 
the  resulting  coprostasis,  and  consequent  dilatation  and 
loss  of  elasticity  of  the  gut.  Other  of  the  lesions  found 
in  the  insane  are  rather  signs  than  causes  of  their  disease; 
that  is,  they  are  either  evidences  of  the  obscure  influence 
exerted  by  the  mind  upon  the  body,  or  of  the  trophic  role 
played  by  the  brain  in  the  nutrition  of  distant  organs,  or, 
finally,  local  expressions  of  a  deeper  general  somatic  state, 
on  which  the  insanity  and  the  somatic  signs  in  question 
rest  in  common.  For  instance,  amenorrhoea  in  women, 
and  torpor  of  the  enteric  tract  in  all  sexes  are  concomitant 
to,  and  not  causative  of,  melancholia.  It  is  hardlj'^  neces- 
sary to  refer  here  to  the  grave  visceral  lesions  found  with 
the  paralytic  insanities,  which  are  results  and  not  causes  of 
the  cerebral  disorder,  and  whose  analogues  have  been  pro- 
duced through  artificial  cerebral  lesions,  in  the  lower  ani- 
mals ;  *  nor  to  similar  somatic  changes,  sometimes  found 
in  cases  of  advanced  epileptic  insanity.f  Even  palpable 
affections  of  the  brain  may  be  accidental  accompaniments 
of  a  mental  disorder,  nay,  even  its  indirect  results!  The 
cysticerci  occasionally  discovered  in  the  brains  of  imbe- 
ciles, terminal  dements,  and  paretics,  developed  from  ova 
introduced  with  the  materials  devoured  in  obedience  to 
the  filthy  propensities  of  such  lunatics,  are  illustrations  of 
the  possibility  of  such  a  curious  relation.]; 

From  the  statements  just  made  it  follows,  that  before  a 
preternatural  appearance,  found  in  the  brain  of  an  indi- 
vidual dying  insane,  can  be  adduced  to  explain  the  nature 
of  the  mental  sj'mptoms,  or  to  illustrate  the  operation  of 

*  By  Brown-Sequard,  Leudet,  Ollivier,  Dupuy,  Eulenburg,  and  others. 

JDufour,  "  Annates  Medico-Psychologiques,"  1880. 
Ullrich,  "  AUgemeine  Zeitschrift  fiir  Psychiatrie,"  1S72,  xxix.  Wendt, 
"  Fall  von  Cysticercus  im  Gehirn,  als  Folge,  nichtals  Ursache  der  Geistes- 
storung."  Ibidem,  1874.  xxxi.  Meschede,  Ibidem,  1S73,  xxv.  The  writer 
has  frequently  found  cysticerci,  single  or  in  numbers  not  exceeding  three, 
in  monkeys  of  the  genera  macacus,  cercopithecus,  cynocephalus,  and 
semnopithecus,  occupying  different  gyri,  including  those  most  carefully 
studied  by  the  localizationists.  In  none  of  these  cases  had  any  symptoms 
of  cerebral  disturbance  been  observed.  It  is,  however,  a  beautiful  illus- 
tration of  the  proposition  that  diffuse  and  multilocular  lesions  of  the 
fore-brain  always  produce  insanity,  that  in  an  earlier  case  of  Wendt's 
("AUgemeine  Zeitschrift  fiir  Psychiatrie,"  xxv.),  where  beside  numerous 
cysticerci  found  in  the  cereoellum  and  basilar  parts,  one  hundred  and 
thirty  were  found  in  the  cerebral  hemispheres,  the  insanity  of  the  subject 
coincided  with  the  probable  period  of  their  development,  as  it  does  in 
analogous  cases  found  among  domestic  animals. 


THE   CLASSIFICATION   OF   INSANITY.  II3 

an  originally  remote  cause,  it  should  be  submitted  to  cer- 
tain tests.  It  must  not  only  be  shown  to  be  independent 
of  spontaneous  changes  occurring  after  death,  and  of  arte- 
facta  produced  by  the  investigator,  but  it  is  also  essential 
that  the  lesion  be  not  one  of  the  same  kind,  extent,  and 
location  as  one  found  as  frequently,  or  more  frequently,  in 
subjects  dying  sane.  It  is  needless  to  remark  that  the 
same  requirements  are  to  be  met,  when  it  is  attempted  to 
establish  a  relation  between  diseased  conditions  found  in 
other  organs  than  the  brain  and  a  co-existing  insanity. 

The  connection  between  a  given  lesion  and  mental  alien- 
ation having  been  rendered  plausible  after  compliance 
with  these  preliminary  demands,  it  remains  to  be  ascer- 
tained whether  the  lesion  as  found  is  merely  related  to  the 
particular  phase  of  insanity  as  it  existed  before  death,  or 
whether  it  explains  also  the  origin  of  the  trouble.  It  is 
here  to  be  insisted  that,  if  the  mental  disorder  is  the 
terminal  phase  of  a  preceding  series  of  mental  symptoms, 
perhaps  differing  in  character  from  their  sequel,  the  dis- 
covered lesion  can  represent  nothing  more  than  the  somatic 
basis  of  the  terminal  phase.  It  may  enlighten  us  as  to  the 
basis  of  the  preceding  mental  phases  and  the  inception  of 
the  original  evil  in  so  far  onh^as  the  principles  of  pathology 
permit  us  to  infer  from  a  post-mortem  appearance  what  the 
initial  steps  of  the  morbid  life-processes  leading  to  it  were. 


CHAPTER   XI. 

The  Classification  of  Insanity. 

While  the  proper  classification  of  insanity  which  was 
initiated  by  the  French  and  carried  further  by  the  German 
alienists  may  be  said  to  be  approaching  a  comparative  state 
of  perfection  on  the  Continent  generally,  it  is  in  America 
and  England  still  in  a  very  chaotic  condition.  Nearly 
every  writer  on  insanity  has  offered  a  classification  of  his 
own.  But  while  the  student  will  find  only  slight  differences 
between  the  classifications  of  a  Marce,  Dagouet,  and  Es- 
quirol,  or  a  Krafft-Ebing,  Schuele,  and  Meynert,  and  the  gen- 
eral principle  of  their  classifications  is  the  same,  he  can  only 
be  confounded  by  a  comparison  of  the  systems  of  a  Maudsley, 


1 14  INSANITY. 

Hammond,  Bucknill-Tuke,  Skae,  and  Sankey.  Suggestive 
hints  and  valuable  demarkations  may  be  found  scattered 
here  and  there  among  the  divisions  of  these  authors;  but, 
on  the  whole,  the  ambition  to  found  new  forms,  often  in- 
volving the  doing  away  with  the  clinical  principles  which 
must  underlie  every  practically  available  definition,  and  to 
establish  formulae  in  place  of  following  observations  as  a 
basis  of  classification,  impair  their  usefulness. 

What  could  be  more  unfortunate  than  an  attempt  to 
classify  insanity  according  to  the  faculties  of  the  mind  sup- 
posed to  be  affected  in  its  various  forms?  Maudsley,  one 
of  the  most  progressive  of  English  alienists,  for  example, 
divides  insanity  as  follows: 

I.    Affective    or    Pathetic    In-  !  II.   Ideational  insanity. 
SANITY.  [       I.   General. 

I.   Maniacal    perversion    of    the  j  a.   Mania.  j  Acute  and 

affective  life.     Mania  sine  deli-  /i.   Melancholia.  \    chronic. 


no. 

2.  Melancholic  depression  with- 
out delusion.  Simple  melan- 
cholia. 

3.  Moral  alienation  proper. 


2.  Partial. 
a.   Monomania, 
/i.   Melancholia. 

3.  Dementia.  \  Pr'^^ry 

•^  (  Secondary. 

4.  General  paralysis. 

5.  Idiocy  and  Imbecility. 


Here  we  have  mania  and  melancholia  distributed  under 
both  heads;  in  one  place  as  affective  and  in  another  as 
ideational  insanity  !  An  attentive  observer  would  often 
find  that  the  same  patient  presents  mania  or  melancholia 
without  delusion  at  one  period  of  his  illness,  and  mania  or 
melancholia  with  delusion  at  another.  In  fact  there  are  few 
cases  of  insanity  which  would  not  be  found  to  occasionally 
occupy  a  place  in  either  of  Maudsley's  great  groups.  Such 
classifications  are  faulty,  because  the}'  lack  clinical  unity  and 
consistency.  The  same  applies  to  several  other  systems  of 
classification  which  are  constructed  on  similar  principles.* 

One  of  the  most  curious  classifications  is  that  which  was 
recommended  by  a  committee  of  the  British  Medico- 
Psychological  Association  in  1869,  but  not  adopted  by  that 
body.     The  fundamental  distinction  is  here  made  of  "cur- 

*  Maudsley  has  been  selected  as  the  most  modern  representative  of 
the  school  which,  with  Griesinger  and  Prichard,  made  the  mental  com- 
plexion of  the  disorder  the  main  guide  in  classification.  He  does  not, 
therefore,  stand  alone,  but  his  error  has  been  a  very  general  one;  and 
there  are  those  who  have  not  yet  emancipated  themselves  from  it. 


THE   CLASSIFICATION   OF   INSANITY.  II5 

able"  and  "  incurable"  forms.  Let  the  reader  imagine  such 
a  principle  applied  to  any  other  class  of  diseases,  say  those 
of  the  intestinal  tract  !  The  proponents  of  this  classifica- 
tion seem  also  to  have  been  aware  of  the  existence  of  but 
one  form  of  senile  insanity,  namely  dementia. 

Morel  was  the  first  to  admit  the  etiological  principle  into 
the  classification  of  mental  disorders.  He  divided  insanity 
into — I.  Hereditary  Insanity  ;  2.  Toxic  Insanity  ;  3.  Insan- 
ity  due  to  the  transformation  of  other  neuroses,  such  as 
epilepsy  and  hysteria  ;  4.  Idiopathic  Insanity;  5.  Sympa- 
thetic Insanity;  6.  Dementia.  While  this  classification  is 
defective  on  account  of  the  insufficient  stress  laid  on  the 
clinical  features  of  insanity,  it  must  be  regarded  as  the  first 
step  toward  that  more  perfect  classification  which  has 
been  recently  proposed  and  defended  by  Krafft-Ebing  and 
other  Germans.  But  a  long  period  passed  before  this  prin- 
ciple was  properly  asserted,  for  it  was  carried  to  an  ex- 
treme, and  rendered  the  vulnerable  object  of  much  ridicule 
by  the  English  followers  of  Morel.  Skae's  twenty  and 
more  etiological  forms,  containing  as  they  do  much  that  is 
useful,  include  also  a  "  post-connubial  insanity,"  which  may 
be  anything  from  Mania  and  Melancholia  to  Paretic  Demen- 
tia; a  Mania  of  Oxaluria  and  Phosphaturia,  which  no  in- 
vestigator has  been  so  fortunate  as  to  be  able  to  confirm 
the  existence  of;  and  manias  of  "pregnancy"  and  "lacta- 
tion," which  may  be  as  often  true  melancholias  as  manias. 
Unable  to  make  even  his  accommodating  system  fit  all 
cases,  Skae  was  compelled  to  erect  an  "Idiopathic"  group, 
which,  in  truth,  contains  over  one  half  of  all  the  known  and 
accepted  forms  of  insanity.  There  is  naturally  no  correct 
balancing  of  the  main  forms  here! 

Dr.  D.  Hack  Tuke  improved  greatly  on  the  classifications 
of  Skae  and  Morel,  attempting  to  combine  the  metaphysical 
and  etiological  principles  into  one.  But,  by  making  the 
former  the  guiding  and  the  latter  the  subsidiary  element, 
he  was  led  into  such  inconsistencies  as  the  placing  of  Mania 
under  "  Intellectual  Insanity,"  and  Melancholia  side  by  side 
with  "  Exaltation,"  and  "  Moral  Insanity"  under  the  "  Emo- 
tional Insanity."  There  is  also  no  placein  his  groups  for 
paretic  dementia.  On  the  other  hand,  "Moral  Insanity," 
placed  by  Dr.  Tuke  under  the  second  order  of  the  second 
class,  that  is,  those  occurring  as  an  "  invasion  after  devel- 
opment," maybe  also  a  manifestation  of  imperfect  develoD- 
ment,  and  therefore  might  fall  under  his  first  order  as  we'l 


Il6  INSANITY. 

The  pathological  principle  has  also  been  made  the  basis 
of  classification.     By  none  has  it  been  carried  further  than 
by  Voisin.     He  divides  acquired  insanity  as  follows:* 
I.  Idiopathic  insanity. 
a.  Due  to  vascular  spasm. 
II,   Insanity  dependent  on  appreciable  brain  lesions. 

a.  Congestive  insanity. 

b.  Insanity  from  anaemia. 

c.  Atheromatous  insanity. 

d.  Insanity  consecutive  to  brain  tumors. 

III.  Insanity  dependent  on  alterations  of  the  blood. 

a.  Diathetic  insanities. 

b.  Syphilitic  insanities. 

This  classification  requires  no  extended  discussion. 
Voisin's  views  as  to  congestion  and  anaemia  in  insanity 
are  utterly  fanciful,  and  it  suffices  to  characterize  the  un- 
systematic application  made  by  this  author  of  his  adopted 
principles,  that  general  paralysis  is  widely  separated  from 
the  other  "  idiopathic  insanities"  with  "  demonstrable  brain 
lesions."  Besides,  Voisin  claims  to  have  determined  a 
pathological  basis  for  nearly  every  form  and  variety  of  in- 
sanity, and  has  in  this  respect  either  anticipated  his  age  or 
has  fallen  into  such  multitudinous  errors  that  it  may  be 
safe  to  pass  by  a  project  which  may  or  may  not  be  realized 
in  the  future,  but  which  at  present  is  decidedly  unfeasible. 

One  of  the  best  classifications  made  within  the  last  decade 
is  that  of  KrafftEbing.f    He  divides  insanity  into  two  great 

*  Le9ons  Cliniques  sur  les  Maladies  Mentales,  1883.     The  classification 
offered  by  the  same  author  in  the  edition  of  1S76  is  more  elaborate. 
Unaccompanied  by  demonstrable  lesions. 
Accompanied  by  demonstrable  lesions. 
I.  Active  congestion. 
I.  Acquired  Insanity.  J       2.   Passive  congestion. 
Idiopathic.  )      3.   Simple  anaemia. 

4.  Secondary  anaemia. 

5.  Atheroma. 

6.  Tumors. 

b.  Following  the  great  neuroses. 

c.  Sensorial  insanity. 

d.  Sympathetic  insanity 
II.   Congenital  insanity, 

III.  Toxic  insanity. 
IV.  Cretinism,  idiocy,  and  imbecility. 
V.   General  paralysis. 
VI.   Senile  dementia. 
f  "  Lehrbuch  der  Psychiatric,"  II.,  1879. 


THE   CLASSIFICATION   OF   INSANITY.  II 7 

groups,  according  as  the  disorder  is  the  result  of  a  disturb- 
ance of  the  developed  brain  or  of  an  arrest  of  brain  develop- 
ment. Under  the  first  head  he  places  insanity  ordinarily 
so  called,  and  subdivides  further  as  follows: 

A.  Mental  affections  of  the  developed  brain. 

I.  Psychoneuroses. 

1.  Primary  curable  conditions. 

a.  Melancholia. 

a.  Melancholia  passiva. 
^.  "  attonita. 

b.  Mania. 

a.  Maniacal  exaltation. 
/?.  "         frenzy. 

c.  stupor. 

2.  Secondary  incurable  states. 

a.  Secondary    monomania    (secundaere    verrueck- 
theit). 

b.  Terminal  dementia. 
a.  Dementia  agitata. 

/?.  Dementia  apathetica. 

II.  Psychical  degenerative  states. 

a.  Constitutional     affective     insanity    (folia    rais- 
sonante). 

b.  Moral  insanity. 

c.  Primary  monomania  (primasre  Verruecktheit). 
a.  With  delusions. 

aoc.   Of  a  persecutory  tinge. 

y5/?.  Of  an  ambitious  tinge. 

/?.  With  imperative  conceptions. 

d.  Insanities  transformed  from  the   constitutional 
neuroses. 

a.  Epileptic. 

/?.  Hysterical. 

y.  Hypochondriacal. 

e.  Periodical  insanity. 

III.  Brain  diseases  with  predominating  mental  symp- 
toms. 

a.  Dementia  paralytica. 

b.  Lues  cerebralis. 

c.  Chronic  alcoholism. 

d.  Senile  dementia. 

e.  Acute  delirium. 

B.  Mental  results  of  arrested  brain  development :  idiocy 
and  cretinism. 


Tl8  INSANITY. 

The  criticism  to  be  made  of  this  classification  is  three- 
fold. In  the  first  place,  it  does  not  accommodate  itself  to 
the  fact  that  there  is  every  connecting  link  between  idiocy 
and  imbecility  on  the  one  hand  and  monomania  on  the 
other.  In  the  second  place,  the  designation  "  Verrueck- 
theit"  is  too  generally  used,  being  made  to  apply  to  two 
very  distinct  forms  of  insanity.  In  the  third  place  it  is  un- 
necessary, as  it  is  inaccurate  to  add  the  adjectives  "cura- 
ble" and  "incurable"  to  the  primary  and  secondary  forms 
of  the  psychoneuroses,  for  in  many  cases  the  primary  dis- 
orders are  not  cured  by  the  very  best  treatment,  and  the 
stamp  of  incurability  seems  to  be  affixed  to  some  cases 
from  the  start. 

It  may  be  readily  surmised  that  where  the  best  thinkers 
have  failed  to  produce  an  unexceptionable  classification, 
the  failure  must  be  due  to  some  inherent  difficulty  of  the 
subject.  Few  cases  of  insanity  are  exactly  alike  in  all  re- 
spects. Here  we  have  a  patient  whose  insanity  is  charac- 
terized by  a  deep  emotional  tinge,  there  one  with  moral 
perversion,  another  with  morbid  propensities,  and  still  an- 
other with  fixed  ideas.  Here  is  an  entire  group  of  asylum 
inmates  without  hallucinations,  illusions,  or  delusions; 
there  another  without  dementia.  Here  is  a  ward  filled  with 
patients  w^hose  mental  symptoms  are  accompanied  by  so- 
matic anomalies;  there  anothei-,  in  which  no  patient  may  be 
found  whose  somatic  state  differs  appreciably  from  that  of 
ordinary  hospital  patients.  The  course  of  this  psychosis  is 
chronic,  of  that  one  acute;  while  in  some  it  is  even,  and  in 
others  progressive.  In  certain  cases  we  find  characteristic 
evidences  of  insanity  in  the  dead  bodies,  in  others  not. 
Sometimes  the  psychosis  is  primary  in  origin,  at  others 
secondary  to  another  psychosis.  Often  the  insanity  exists 
by  itself,  and  often  it  accompanies  and  is  determined  in  its 
existence  by  some  other  complaint.  Several  forms  are 
hereditar}'^  or  congenital,  and  others  are  independent  of 
congenital  and  hereditary  influences.  More  than  one  form 
of  insanity  is  intimately  associated  with  developmental 
periods,  while  the  majority  may  appear  at  any  time  of  life. 
In  short,  there  is  every  possible  association  of  factors  seem- 
ing to  distinguish  various  groups  of  the  insane,  and  none 
of  these  can  be  altogether  ignored  in  classification.  For 
this  reason  all  attempts  to  classify  the  form  of  insanity  ac- 
cording to  any  one  given  invariable  principle  are  predes- 
tined to  failure. 


THE   CLASSIFICATION   OF   INSANITY.  II9 

Let  us  walk  through  an  asylum  for  the  insane  with  an 
experienced  alienist,  and  observe  his  method  of  diagnosti- 
cating and  classifjnng  the  insane.  He  will  not  point  out 
to  the  visitor  any  cases  of  "  ideational,"  "atheromatous,"  or 
"post-connubial"  insanity,  but  he  will  show  him  a  mono- 
maniac, a  melancholiac,  a  paretic  dement,  or  a  stuporous 
lunatic;  and  he  will  be  able  to  pick  out  a  large  number  of 
patients,  place  them  together,  and  demonstrate  the  general 
sameness  in  the  symptoms  of  all  monomaniacs,  or  of  all 
paretic  dements,  or  of  all  patients  belonging  to  any  one  of 
the  other  clinical  groups.  If  he  make  any  finer  distinction, 
he  may  remark  that  in  such  and  such  a  patient  the  disor- 
der is  hereditary;  that  in  this  patient  the  delusions  are  de- 
pressive, in  that  one  expansive,  and  occasionally  he  may 
allude  to  the  fact  that  in  certain  patients  the  type  of  the 
disorder  is  determined  by  the  etiology;  that,  for  example, 
it  may  be  alcoholic  or  epileptic  in  character.  Let  us  now 
follow  him  to  the  "demented  ward."  Here  he  will  exhibit 
a  number  of  patients  who  seem  to  be  all  equally  sunken 
into  a  condition  of  mental  apathy  and  deterioration.  But, 
on  the  alienist's  directing  attention  to  certain  points  in 
their  past  and  present  history,  distinct  types  of  "dementia" 
will  become  recognizable  even  to  the  novice.  This  patient 
who  still  exhibits  a  few  faintly  expressed  delusions  was 
originally  a  maniac,  then  his  insanity  became  a  chronic 
confusional  delirium  which  has  gradually  passed  into  what 
is  properly  called  a  fermina/  dementia.  A  second  patient  has 
passed  into  a  demented  state  by  a  gradual  and  progressive 
deterioration  from  a  previous  condition  of  mental  health; 
his  dementia  is  a. primary*'  one,  and  not  secondary  to,  nor 
the  terminal  epoch  of  some  other  form  of  insanity.  A 
third  has  epileptic  convulsions,  and  his  dementia  is  the  se- 
quel of  epilepsy  and  consequently  an  epileptic  dementia. 
A  fourth  has  had  a  haemorrhage  or  other  destructive  lesion 
of  the  brain,  and  his  feeble-mindedness  is  attributable  to 
that;  in  other  words,  he  suffers  from  donentia  with  coarse  or- 
ganic disease  of  the  brain.  A  fifth  presents  a  peculiar  and 
characteristic  grouping  of  motor  and  sensory  disturbances, 
and  intellectual  and  moral  perversion  combined  with  men- 
tal failure,  which  in  their  union  constitute  paretic  demen- 
tia.    In  still  another  patient  the  dementia  is  senile,  because 

*This  term  has  been  used  very  confusedly;  for  explanation  of  the 
sense  in  which  it  is  used  here  see  "  Primary  Deterioration." 


120  INSANITY. 

it  is  an  expression  of  the  involution  of  age.  Finally,  a  pa- 
tient will  be  shown  who  is  apparently  in  the  lowest  depths 
of  mental  annihilation;  but  the  alienist  assures  the  visitor 
that  the  disorder  is  not  a  progressive  but  a  temporary  one; 
that  it  is  an  overwhelming  of  the  mind  by  some  emotional 
shock,  or  the  result  of  an  episodial  brain-exhaustion,  and 
that  in  nine  cases  out  of  ten  the  patient  will  emerge  from  his 
present  state  clothed  in  his  right  mind.  Such  a  case  is  one 
of  so-C3.\\Q.d primary  acute  dementia,  better  known  as  stupor- 
ous insanity.  As  the  novice  is  made  better  acquainted  with 
the  psychical  features  of  these  groups,  he  will  find  that  the 
distinctions  on  which  they  are  based  do  not  exist  alone  in 
the  antecedent  history  of  the  patients;  but  that  as  a  gen- 
eral thing  the  character  of  the  symptoms  of  each  of  them 
has  something  specific:  that  the  senile  dement  is  miserly 
and  suspicious,  the  paretic  dement  boastful  and  extrava- 
gant, while  tlie  terminal  dement  is  either  apathetic  or  agi- 
tated according  to  the  nature  of  his  primary  mental  disorder, 
and  that  he  often  exhibits  the  residual  delusions  developed 
with  the  latter. 

If  the  origin  and  prospects  of  various  cases  of  so  appar- 
ently simple  a  disorder  as  dementia  are  so  widely  different 
as  is  here  adverted  to,  it  may  be  readily  conceived  that,  with 
regard  to  the  more  positive  manifestations  of  insanity,  the 
distinctions  must  be  still  greater,  and  even  more  important 
as  diagnostic  and  prognostic  criteria.  It  would  be  mani- 
festly improper  to  place  all  patients  manifesting  maniacal 
excitement  in  one  common  group.  Maniacal  excitement 
may  be  an  indication  of  a  disorder  consisting  of  this  ex- 
citement as  the  sole  prominent  symptom,  namely,  of  simple 
mania;  it  may  occur  as  an  episode  oi paretic  dementia  and  in 
epileptic  insanity;  finally,  it  may  be  the  recurrent  manifesta- 
tion of  3.  periodical  insanity,  or  characterize  the  explosion  of 
a  toxic  affection.  As  insanity  is  after  all  but  the  sympto- 
matic manifestation  of  a  brain  disorder,  and  the  pathological 
states  underlying  insanit)'^  are  not  well  known,  obviously 
the  simplest  and  most  profitable  plan  of  classification  will 
be  the  adoption  of  the  clinical  method  as  our  main  guide; 
then  where  etiology,  pathology,  and  speculative  psychology 
furnish  valuable  distinctions  we  may  incorporate  them  as 
collateral  aids  in  such  classification. 

The  first  distinction  to  be  made  is  between  those  cases 
in  which  the  insanity  is  the  directlv  produced  and  most  im- 
portant disorder  manifested    by   tlie   patient,  and    those   in 


THE   CLASSIFICATION   OF   INSANITY.  121 

which  the  insanity  is  an  accidental  and  inconstant  accom- 
paniment of  other  diseases,  and  has  its  nature  modified  by 
these.  The  first  group  may  be  designated  as  that  of  the 
Pure  Insanities,  and  the  second  as  that  of  the  Complicat- 
ing Insanities.  Paretic  dementia,  simple  mania,  imbe- 
cility, monomania,  and  alcoholic  insanity  are  the  direct 
expression  of  d\sordQ.vs priinan'Iy  attacking  the  brain;  are  fiot 
fiecessariiy  dependent  on  any  other  disordered  bodily  condi- 
tion, and  if  attributable  to  such  a  condition  are  not  thereby 
modified  to  any  important  extent.  Rheumatic  insanity, 
pellagrous  insanity,  and  the  post-febrile  psychoses  are  essen- 
tially dependent  on  disorders  which  are  not  primarily  cere- 
bral in  their  location,  and  their  symptoms  are  specifically 
modified  by  an  originally  >ion-cerebral  ca.usc. 

In  the  class  of  the  "  pure  insanities"  two  great  divisions 
must  be  made.  There  is  one  group  comprising  mental 
disorders  which  affect  persons  previously  of  sound  mind, 
somewhat  after  the  manner  in  which  a  fever  or  a  diarrhoea 
attacks  a  person  of  previously  sound  bodily  health.  The 
insanity  here  is  not  the  explosion  of  a  continuous  morbid 
condition,  but  stands  by  itself  an  isolated  occurrence"^  in  the 
midst  of  a  relatively  healthy  career  which  it  may  check  and 
end.  The  other  group  comprises  disorders  which  are  the 
explosions  of  a  continuous  neurotic  condition,  which  may  be 
inherited  from  a  vitiated  ancestry,  acquired  through  intra- 
uterine or  infantile  brain  disease,  or  developed  under  the 
influence  of  injuries  to  the  skull  and  brain,  or  of  excesses 
in  the  use  of  certain  narcotics.  In  a  rude  way  the  first 
group  corresponds  to  Krafft-Ebing's  "  Psychoneuroses" 
and  "  Brain  Diseases  with  Predominating  Mental  Symp- 
toms" united  into  one  class;  the  second  group  is  nearly 
equivalent  to  the  combined  "  Psychical  Degenerative 
States"  and  "  Mental  Results  of  Arrested  Brain  Develop- 
ment" of  the  same  author. 

Pure  insanity  not  intrinsically  dependSnt  on  a 
CONTINUOUS  neurotic  VICE  is  in  turn  divisible  into  sub- 
groups. The  first  is  not  associated  with  demonstrable 
active  organic  changes  of  the  brain,  while  the  second  is  so 
associated.  Simple  mania  is  a  type  of  the  first  sub-group, 
paretic  dementia  of  the  second. 

Pure   insanity    not    intrinsically   dependent    on    a 

*  Isolated  in  the  sense  in  which  the  term  may  be  applied  to  fevers  or 
other  affections  of  the  kind.  A  recurrence  is  not  excluded,  but  it  is  never 
typical. 


122  INSANITY. 

CONTINUOUS  NEUROTIC  VICE,  NOR  ASSOCIATED  WITH  DEMON- 
STRABLE   ACTIVE    ORGANIC    CHANGES    OF    THE    BRAIN    is    again 

divisible  into  sub-groups.  In  a  first  subdivision  we  find  in- 
sanities which  attack  individuals  irrespective  of  the  physi- 
ological periods  of  development  and  involution,  while  in  a 
second  subdivision  they  are  intimately  connected  with  such 
periods.  Simple  mania  and  melancholia  are  instances  of 
the  first  kind,  while  insanity  of  pubescence  is  an  instance  of 
the  second  kind. 

Pure  insanities   not   intrinsically   dependent    on  a 

CONTINUOUS  neurotic  VICE,  NOR  ASSOCIATED  WITH  DEMON- 
STRABLE ACTIVE  BRAIN  CHANGES,  NOR  RELATED  TO  THE 
PERIODS    OF     DEVELOPMENT     AND     INVOLUTION     include    mOSt 

of  the  curable  cases  of  mental  disorder.  They  present 
themselves  under  two  distinct  forms,  according  as  the  dis- 
order is  primary  or  secondary  to  one  of  the  other  forms  of 
the  same  series.  Simple  melancholia  and  acute  confusional 
insanity  are  representative  of  the  Primary  Forms,  and  ter- 
minal dementia  and  chronic  confusional  insanity  are  ex- 
amples of  the  Secondary  Forms  coming  under  this  head. 

The  PRIMARY  INS.A.NITIES  uot  intrinsically  dependent  on  a  con- 
tinuous neurotic  vice,  nor  associated  with  demonstrable  active  brain 
changes,  nor  related  to  the  periods  of  development  and  involution^ 
consistently  with  the  dichotomous  division  which  happens 
to  mark  this  branch  of  psyclnatrical  classification,  naturally 
fall  into  two  categories.  In  one  the  insanity  is  always  char- 
acterized by  a  fundamental  emotional  disturbance.  To  this 
category  belong  mania,  marked  by  an  exalted  emotional 
state;  melancholia,  marked  by  a  painful  emotional  state; 
katatonia,  marked  by  a  pathetic  emotional  state;  and  transi- 
tory frenzy.  In  the  other  category  there  is  an  absence  of 
any  profound  emotional  disturbance.  To  this  category  be- 
long primary  dementia,  stuporous,  and  acute  confusional  insanity. 
The  SECONDARY  INSANITIES  belonging  to  the  same  sub-group 
include  terminal  detnentia  and  chronic  confusional  deterioration. 

Pure  insanity  not  intrinsically  dependent  on  a  continuous  neu- 
rotic vice,  nor  associated  with  demonstrable  active  organic  changes 
of  the  brain,  but  related  to  the  periods  of  development 
AND  INVOLUTION,  Comprises  only  two  forms:  insanity  of  pu- 
bescence (the  hebephrenia  of  Hecker-Kahlbaum),  and  senile 
dementia.  It  is  a  matter  of  doubt  whether  a  number  of 
cases  of  insanity  occurring  at  the  time  of  the  second  climac- 
teric justify  the  erection  of  a  special  genus  for  their  accom- 
modation under  this  head. 


THE    CLASSIFICATION    OF   INSANITY.  1 23 

The  pure  insanities  which  are  not  the  outcome  of  a  continu- 
ous neurotic  vice,  and  are  associated  with  active  organic 
BRAIN  changes,  include  paretic  dementia,  delirium  grave  (the 
manie  grave  of  the  Frencli),  syphilitic  dementia,  and  organic  de- 
mentia. Under  the  latter  term  the  mental  defects  accom- 
pan  ving  gross  disease  of  the  brain,  such  as  cysticerci,  tumors, 
h3'pertrophy,  atrophy,  sclerosis,  and  the  ordinary  cerebral 
vascular  lesions  are  included.* 

The  pure  insanities  which  are  the  outcome  of  a  con- 
tinuous NEUROTIC  vice  OR  TAINT  are  those  to  whose  patho- 
genesis the  conclusions  of  the  ninth  chapter  apply  in  great 
part.  The  neurotic  vice  may  manifest  itself  in  a  gross  and 
general  defect  in  brain  development  as  in  idiocy;  in  lesser 
defects  associated  with  anomalies  in  the  cranial  shape  and 
peripheral  growth  and  innervation,  as  in  cretinism,  imbecil- 
ity, and  original  monomania;  in  convulsions  during  child- 
hood; or  in  a  generally  neurotic  constitution  and  mentally  ab- 
normal character.  The  mental  disorder  may  date  from  birth, 
from  the  period  of  puberty,  or  from  the  second  climacteric, 
on  the  one  hand,  or  it  may  be  developed  by  exciting  causes 
at  any  time  of  life,  on  the  other.  The  neurotic  vice  is  not 
necessarily  transmitted;  it  may  be  acquired  through  trau- 
matism, and  the  formation  of  the  alcoholic  or  other  narcotic 
habit;  and  it  may  also  gradually  develop  on  the  basis  of 
any  of  the  constitutional  neuroses,  such  as  epilepsy  and 
hysteria. 

It  is  impracticable  to  separate  the  forms  of  these  properly 
so-called  constitutional  insanities  into  subdivisions  based  on 
the  intensity  or  character  of  the  transmitted  vice.  Gross 
anatomical  defects  or  lesser  somatic  indications  of  defective 
brain  development  are  found  indifferently  in  several  of  the 
forms  of  insanity  belonging  to  this  series;  but  they  may  be 
undemonstrable  in  the  very  same  forms,  and  only  the  neu- 
rotic character  may  serve  to  characterize  the  predisposed 
person  as  a  defectively  organized  individual.  Attention  has 
been  already  (Chapter  IX.)  directed  to  the  fact  that  any 
form  of  insanity  in  this  series  may  be  transformed  into  an- 
other, and  that  the  anatomical  defects  sometimes  noted 
may  be  intensified  in  the  course  of  hereditary  transmission, 
or  become  potent  in  a  descendant  when  they  were  absent  in 
the  ancestor.     It  was  also  observed  at  the  same  place  that 

*  This  form  will  not  be  considered  in  this  treatise,  except  in  its  dif- 
ferential diagnostic  relations. 


124  INSANITY. 

science  was  not  yet  able  to  determine  what  kind  of  anomaly 
determined  the  existence  of  a  given  form  of  hereditary  or 
constitutional  insanity.  The  same  kind  of  asymmetry  has 
been  found  in  monomania  and  imbecility. 

A  very  natural  distinction  can  be  made  between  those 
forms  in  which  the  insanity  is  associated  with  the  great 
neuroses,  and  those  in  which  there  is  no  such  association, 
and  if  there  be,  that  association  is  accidental.  An  idiot  may 
have  epileptic  attacks,  but  his  idiocy  is  not  dependent  on 
these,  but  on  the  brain-defect  with  which  he  was  born.  A 
monomaniac  may  have  hysterical  or  epileptiform  symptoms, 
though  these  are  accidental  to,  and  do  not  essentially  mod- 
ify tlie  monomania.  But  there  are  epileptic  and  hysterical 
patients  who  develop  an  insanity  intimately  dependent  on 
the  neurosis,  and  whose  symptoms  have  a  specifically  epi- 
leptic or  hysterical  character.  Similarly  any  lunatic  be- 
longing to  these  groups  may  become  an  inebriate,  but  it  is 
either  a  result  or  an  accident  in  monomania,  imbecility,  and 
periodical  insanity,  while  in  the  alcoholic  maniac  the  insan- 
ity is  the  direct  outgrowth  of  and  modified  in  its  symptoms 
by  the  acquired  alcoholic  neurosis. 

The  pure  insanities  which  are  the  expression  of  a 
continuous  neurotic  vice,  but^  not  dependent  on  the 
GREAT  NEUROSES,  Comprise  idiocy,  itnbedlity,  creti/iic  insanity, 
vwnoinania,  and  periodical  insanity;  those  which  are  depen- 
dent ON  THE  GREAT  NEUROSES  Comprise  epileptic,  hysterical, 
and  alcoJwlic  insanity. 

The  COMPLICATING  FORMS  are  as  numerous  as  the  somatic 
causes  which  may  determine  the  existence  and  modify  the 
character  of  insanity.  It  is  customary  to  designate  that 
insanity  following  injuries  to  the  skull  and  which  has  cer- 
tain specific  clinical  characters  as  traumatic  insanity;  that 
following  rheumatism  and  gout  as  rhenmatic  and  gonty  in- 
sanity; that  accompanying  chorea,  as  choreic  insa?iity;  that 
developing  in  the  course  of  phthisis  as  phthisical  insanity; 
and  that  due  to  powerful  reflex  influences  as  sympathetic  in- 
sanity. Many  of  these  forms  are  rare,  others  of  only  ex- 
ceptional occurrence,  but  they  deserve  a  separate  place  be- 
cause their  symptoms  do  not  correspond  exacth'  to  those 
of  the  "  pure  forms,"  and  their  treatment  is  directly  to  be 
based  on  the  etiology.  Indeed,  they  may  be  called  the  eti- 
ological forms.  One  form  appertaining  to  this  series, 
pellagrous  insanity,  will  not  be  discussed  in  this  volume,  as  it 
does  not  occur  in  America,  and  is  limited  to  such  countries 


THE   CLASSIFICATION    OF   INSANITY.  12$ 

as  Italy,  where  maize  forms  a  staple  article  of  diet,  and 
where  the  disease  known  a.s pellagra,  which  is  attributed  to 
the  living  on  spoiled  maize,  occurs  in  an  endemic  form.* 

A  glance  at  the  subjoined  table  will  give  a  better  idea  of 
the  proposed  classification  than  any  further  description.  It 
will  be  observed  that  on  adding  the  designation  character- 
izing the  species  to  that  of  the  genus  and  the  class,  a  defi- 
nition of  many  of  the  enumerated  forms  can  be  compounded. 
Thus:  Melancholia  is  a  simple  insanity,  not  essentially  the 
manifestation  of  a  continuous  neurotic  condition,  not  asso- 
ciated with  demonstrable  active  organic  changes  of  the 
brain,  attacking  the  individual  irrespective  of  the  develop- 
mental and  involutional  periods,  of  primary  origin  and 
characterized  by  a  fundamental  emotional  disturbance  of  a 
painful  character.  Insanity  of  pubescence  is  a  simple  in- 
sanity, not  essentially  the  manifestation  of  a  continuous 
neurotic  condition,  not  associated  with  demonstrable  active 
organic  brain  changes,  attacking  the  individual  in  connec- 
tion with  the  period  of  puberty.  Paretic  dementia  is  a 
simple  insanity,  not  essentiall}^  the  manifestation  of  a  con- 
tinuous neurotic  condition,  associated  with  demonstrable 
organic  changes  of  the  brain,  which  are  diffuse  in  distribu- 
tion, primarily  vaso-motor  in  origin,  and  destructive  in  their 
results.  As  a  rule  much  briefer  definitions  will  serve  the 
purposes  of  the  alienist,  but  the  fact  that  the  proposed 
classification  carries  with  it  the  terms  of  these  definitions 
will  seem  to  many  the  strangest  proof  of  its  consistency. 

It  is  claimed  in  behalf  of  this  classification,  that  while  it 
is  far  from  being  above  criticism  in  many  particulars,  it  is 
calculated  to  meet  the  requirements  of  the  practical  alienist, 
in  those  respects  in  which  the  other  classifications  referred 
to  fail. 

It  may  be  objected  to  on  the  following  grounds,  and  it  is 
proper  to  take  up  those  objections  which  can  be  antici- 
pated seriatim  and  at  this  point. 

It  may  be  claimed  that  the  maniacal  symptom  group 
being  found  in  certain  cases  of  periodical  insanity  as 
well  as  in  simple  mania,  the  two  should  not  be  widely 
separated.  To  this  it  may  be  answered  that  in  simple 
mania,  the  emotional  disturbance  is  the  sole  essential  fea- 
ture, while  periodical  recurrence  and  a  neurotic  constitu- 

*  The  other  complicating  forms  will  be  considered  incidentally  in  the 
chapter  on  Etiology. 


126  INSANITY. 

INSANITY. 
GROUP  FIRST.    PURE  INSANITIES. 

SUB-GROUP    A. 

Simple  Insanity,  not  essentially  the  manifestation  of  a  constitutional  neurotic  con- 
dition. 

FIRST   CLASS. 

Not  associated  with  demonstrable  active  organic  changes  of  the  brain. 
1.  Division.     Attacking  the  individual  irrespective  of  the  physiological  periods. 


Genus  5  :  with  simple  impairment  or  abo- 
lition of  mental  energy. 

Stuporous  Insanity 
Genus  6:  with  comusuniai  adiiium. 

Primary  Confusional  Insanity 
Genus  7:    wiih    uncomplicated    progres- 
sive mental  impairment. 

Pi-inaary  Deterioration 
P  Order  :  Of  secondary  origin. 
Genus  8 :  Secondary  Confusional  In- 
sanity 
Genus  9  :  Terminal  Dementia 


«  Order  :  Of  primary  origin. 
Sub-order  A.     Characterized  by  a  funda- 
mental emotional  disturbance. 
Genus  1 :  of  a  pleasurable  and  expansive 

character Simple  Alania 

Genus  3 :  of  a  painful  characier. 

Simple  Melancholia 
Genus  3:  of  a  pathetic  character. 

Katatonia 

Genus  4 :  of  an  explosive  transitory  kind. 

Transitory  Frenzy 

Sub-order  B.     Not  characterized  by  a  lun- 

damental  emotional  disturbance. 

II.  Division.    Attacking  the  individual  in  essential  connection  with  the  developmental 
or  involutional  periods.     (A  single  order.) 

Genus  10:  with  senile  involution Senile  Dementia 

Genus  11:  with  the  period  of  puberty Insanity  of  Pubescence  (Hebephrenia) 

SECOND    CLASS. 

Associated  with  demonstrable  active  organic  changes  of  the  brain.    (Orders  coincide 

with  genera.) 
Genus  13  :  which  are  diffuse  in  distribution,  primarily  vaso-motor  in  origin,  chronic  in 

course,  and  destructive  in  their  results I'aretic  Dementia 

Genus  13  :  having  the  specific  luetic  character Syphilitic  Dementia 

Genus  14 :  of  the  kind  ordinarily  encountered  by  the  neurologist,  such  as  encephalo- 
malacia,  haemorrhage,  neoplasms,  meningitis,  parasites,  etc. 

Dementia  from  Coarse  Brain  Disease 
Genus  15  :  which  are  primarily  congestive  in  character  and  furibund  in  development. 

Delirium  Grave  (Acute  Delirium,  Manie  grave) 

SUB-GROUP    B. 
Constitutional  Insanity,  essentially  the  expression  of  a  continuous  neurotic  condition. 

THIRD    CLASS. 

Dependent  on  the  great  neuroses  (orders  and  genera  coincide). 

I.  Division.     The  to.xic  neuroses. 

Genus  16  :  due  to  alcoholic  abuse Alcoholic  Insanity 

(Analogous  forms,  such  as  those  due  to  abuse  of  opium,  the  bromides,  and 
chloral,  need  not  be  enumerated  here,  owing  to  their  rarity.) 

II.  Division.     The  natural  neuroses. 

Genus  17:  the  hysterical  neurosis Hysterical  Insanity 

Genus  18:  the  epileptic  neurosis Epileptic  Insanity 

FOURTH   CLASS. 
Independent  of  the  great  neuroses  (representing  a  single  order). 

Genus  19:  In  periodical  exacerbations Periodical  Insanity 

/-,..„      „„.„j  j„„„i „„.  t  Genus  30  :  Idiocy  and  Imbecility 

Order :  arrested  development  ■,  gg^,,^  3,  .  cretinism 

Genus  22:  manifesting  itself  in  primary  dissociation  of  the  mental  elements,  or  in  a 
failure  of  the  logical  inhibitory  power,  or  of  both Monomania 

GROUP  SECOND.     COMPLICATING  INSANITIES. 

These  may  be  divided  into  the  following  main  orders,  which,  as  a  general  thing,  are 
at  the  same  time  genera:  Traumatic,  Choreic,  Post-febrile,  Rheumatic, 
Gouty,  Phthisical,  Sympathetic,  Pellagrous. 


THE   CLASSIFICATION   OF   INSANITY.  12/ 

tion  are  necessary  additional  elements  in  periodical  insanity. 
Inasmuch  as  these  latter  features  determine  the  grave 
prognosis  of  periodical  insanity,  they  are  of  greater  prac- 
tical import,  as  they  are  certainly  of  higher  significance, 
from  an  abstract  pathological  point  of  view,  than  the 
symptomatic  direction  in  which  the  disorder  manifests 
itself.  Consequently  the  neurotic  predisposition  and  peri- 
odical recurrence  of  the  malady  must  as  criteria  determin- 
ing classification  rank  higher  than  the  symptoms/^/-  se. 

It  may  also  be  urged  that  heredity  and  the  neurotic 
constitution,  while  they  do  not  play  as  important  a  part  in 
the  simple  as  in  the  constitutional  forms  of  insanity,  yet 
they  occasionally  and  in  some  forms,  as  in  melancholia, 
quite  frequently  accompany  the  simple  forms.  But  it  is 
exceedingly  rare  for  the  patients  suffering  from  a  simple 
insanity  to  Q.xh\b\\.  s.  continuous  neurotic  condition,  and  where 
they  do  manifest  it,  then  "  simple"  insanity  attacks  them, 
as  an  acute  disease  may  attack  a  previously  healthy  individ- 
ual and  evenly  with  one  suffering  from  chronic  disease  or  a 
constitutional  vice  but  without  any  tangible  connection  with 
such  chronic  disorder  or  constitutional  vice.  An  individual 
may  inherit  syphilis  and  become  attacked  by  an  acute 
pneumonia,  but  we  do  not  speak  of  such  a  pneumonia  as  a 
syphilitic  pneumonia;  or  another  may  have  the  tuberculous 
predisposition  and  die  with  a  surgical  affection,  and  while 
— this  is  said  merely  for  the  sake  of  offering  an  analogy 
— the  statistics  might  show  that  more  tuberculous  subjects 
die  of  surgical  affections  of  a  given  kind  than  non-tuber- 
culous subjects,  yet  until  a  more  intimate  relation  could 
be  shown  between  the  vitiated  constitution  and  the  local 
disease,  we  would  hesitate  to  speak  of  surgical  affections 
in  these  cases  as  of  the  "  tuberculous"  variety.  It  is  the 
same  with  insanity:  certain  varieties  like  monomania  and 
imbecility  are  almost  invariably  associated  with  an  ac- 
quired or  transmitted  neurotic  vice,  and  on  comparing  a 
large  number  of  cases  exhibiting  these  forms  of  derange- 
ment it  is  found  that  there  is  on  the  whole  a  sameness 
in  the  origin  and  nature  of  the  symptoms.  On  the  other 
hand,  simple  mania,  stuporous  insanity,  and  other  of  the 
simple  forms  are  not  as  a  rule  associated  with  such  taint, 
may  attack  persons  previously  healthy  and  free  from 
hereditary  taint,  and  are  noted  for  an  absence  of  those 
characters  found  with  the  constitutional  forms.  Syphilis 
and  the  tuberculous  diathesis  are  undoubtedly  transmitted, 


128  INSANITY. 

and  the  clinician  is  justified  in  characterizing-  certain  medi- 
cal and  surgical  affections  from  which  subjects  of  such 
transmission  suffer  as  the  outcome  of  an  hereditary  or  con- 
stitutional vice.  But  he  will  not  place  incidental  affections 
of  exactly  the  same  character  as  those  affecting  the  sane 
population — for  example,  ordinary  catarrhs,  attacks  of  in- 
digestion, of  diarrhoea,  or  the  exanthemata — in  the  same 
category  with  the  results  of  the  constitutional  affection. 
Just  as  a  syphilitic  subject  may  become  affected  with  small- 
pox, so  an  imbecile  may  become  a  sufferer  from  acute 
melancholia  ;  and  just  as  a  child  afflicted  with  any  hered- 
itary cachexia  may  be  carried  off  by  a  scarlatina  or  diphthe- 
ria, so  a  monomaniac  may  end  his  days  as  a  paretic  dement. 
It  is  needless  to  add  that  the  occasional  development  of 
one  form  of  insanity  in  a  subject  already  suffering  from 
some  other  form  is  no  more  a  ground  for  considering  the 
two  affections  to  be  inseparable,  than  it  would  be  just  to 
classify  peritonitis  and  impaction  of  biliary  calculi  as  vari- 
ties  of  one  and  the  same  disease  because  the  former  may 
complicate  the  latter. 

One  of  the  strongest  objections  to  be  advanced  against 
the  proffered  classification  is  that  alcoholic  insanity  and 
senile  dementia  are  placed  remotely  from  the  forms  which 
like  paretic  dementia  and  acute  delirium  are  associated 
with  demonstrable  active  organic  changes.  It  is  true  that 
considerable  organic  disease  may  be  found  in  senile  de- 
mentia and  in  alcoholic  insanity.  But  in  the  former  dis- 
order these  changes  are  the  passive  ones  of  involution,  and 
not  fresh  processes  attacking  the  previously  sound  brain. 
As  to  insanity  developing  on  an  alcoholic  basis,  those  cases 
of  it  in  which  gross  changes  are  found — changes  which  in 
that  group  of  cases  seem  to  stand  in  a  constant  relation  to 
the  symptoms — do  not  belong  to  alcoholic  insanity  proper, 
but  constitute  a  variety  of  paretic  dementia  or  insanity 
from  coarse  organic  disease.  The  symptoms  are  then  of 
an  entirely  different  character,  the  morbid  changes  are  both 
demonstrable  and  of  an  active  kind,  and  the  consistency  of 
the  classification  proposed  is  nowhere  better  shown  than 
here,  where  insanity  which  has  a  similar  etiology,  but  a 
different  clinical,  pathological,  and  prognostic  character 
from  the  alcoholic  forms  properly  so-called,  is  removed  from 
them  by  the  terms  of  the  definition  heading  the  group  in 
question. 

A  further  objection  may  be  based  on  the  fact  that  de- 


THE   CLASSIFICATION   OF   INSANITY.  129 

mentia  from  organic  disease  and  dementia  from  cerebral 
syphilis  are  not  ranked  with  rheumatic,  pellagrous,  and 
post-febrile  insanity.  It  may  be  alleged  that  they  should 
be  so  ranked  because  they  are  all  equally  among  the  un- 
usual manifestations  of  other  diseases  than  those  which  fall 
within  the  ordinary  ken  of  the  alienist,  and  are  hence  true 
coiiiplicatiug  forms.  To  this  weighty  objection  it  can  be 
replied,  that  insanity  from  the  physiological  psychologist's 
point  of  view  is  a  manifestation  of  brain  disorder  ;  that  we 
are  correct  in  assuming  that  the  ordinary  psychoses  are 
true  cerebral  affections,  primarily  of  cerebral  origin,  and 
that  it  would  be  unwise  from  a  patho-anatomical  point  of 
view — little  as  we  actualh^  know  of  mental  morbid  anatomy 
— to  separate  the  organic  affections  of  the  brain  producing 
insanity,  even  though  they  produce  it  but  occasionally, 
from  the  known  and  hypothetical  diseases  of  the  same 
organ  producing  those  symptoms  more  regularly.  Besides, 
by  retaining  the  distinction  between  those  forms  which  never 
exist  without  an  essential  extra-cerebral  disorder  from  those 
in  which  a  cerebral  disorder  is  the  primary  determining 
factor,  attention  is  prominently  directed  to  certain  useful 
therapeutical  purposes. 

About  one  fact  there  can  be  no  dispute,  that,  excluding 
the  "complicating  forms,"  the  majority  of  the  distinctions 
made  will  be  recognized  as  necessary  by  the  practical 
alienist.  In  a  properly  drawn  up  table  of  any  asylum  of 
over  five  hundred  beds  the  reader  will  find  that  mania, 
melancholia,  stuporous  insanity,  primary,  terminal  (second- 
ary), senile,  and  paretic  dementia,  dementia  from  organic 
disease,  acute  delirium,  alcoholic,  hysterical,  epileptic,  and 
periodical  insanity,  states  of  arrested  development,  and 
monomania — possibly  under  the  more  popular  though  less 
exact  title  of  "  chronic  delusional  insanity" — all  have  a  place. 
It  may  be  assuredlj'  claimed  that  these  distinctions  having 
stood  the  test  of  time  must  possess  a  practical  value.  The 
day  is  past  when  the  asylum  physician  can  content  himself 
with  such  a  classification  as  this  one.* 

Mania:  acute,  sub-acute,  chronic,  recurrent. 

Melancholia:  acute,  chronic. 

Dementia:  primary,  secondary,  senile. 

Amentia  (!):  idiocy,  imbecility. 

General  paresis. 

*  Taken  from  the  annual  report  of  the  New  York  City  Asylum  for  the 
Insane,  dated  January  ist,  1879. 


I30  INSANITY. 

The  average  asylum  attendants — and,  in  more  than  one  in- 
stance noted  by  the  writer,  the  asylum  inmates  themselves 
— are  capable  of  mastering  and — as  far  as  an  application 
can  be  spoken  of — of  applying  such  a  system.  When  every 
excited  patient  is  considered  maniacal,  every  depressed  one 
melancholic,  every  apathetic  one  a  dement,  and  every  stam- 
merer a  paretic,  there  is  simpl)'  an  end  of  scientific  psych- 
iatry, and  if  sight  can  be  lost  for  a  moment  of  the 
pathological  and  clinical  aspects  of  the  subject,  the  reflection 
remains  that  such  a  classification  is  equally  unfortunate 
from  a  practical  point  of  view.  It  leads  to  that  dangerous 
routine  which  gives  chloral  and  conium  to  the  excited, 
opium  to  the  depressed,  and  nothing  to  the  apathetic 
patient,  merely  because  they  are  excited,  depressed,  or 
apathetic. 

While  the  same  strong  grounds  advanced  for  the  con- 
sideration, as  separate  forms,  of  those  varieties  of  insanity 
mentioned  at  the  opening  of  the  above  paragraph  do  not 
hold  good  with  the  others;  that  is,  while  the  latter  are  not 
universally  recognized  to  be  as  distinct  as  the  former  by 
eminent  authorities,  it  is  believed  by  the  writer  that  they 
merit  such  consideration.  For  whatever  disposition  the 
future  wull  make  of  them,  it  may  be  confidently  predicted 
that  the  symptom  groups  of  transitor)'  frenz}',  primary 
confusional  insanity,  katatonia,  and  the  etiological  forms 
will  continue  to  be  subjects  for  study,  and  present  im- 
portant problems  of  differential  diagnosis,  prognosis,  and 
therapeusis  to  those  alienists  who  analyze  the  symptoms  of 
their  patients  not  according  to  preconceived  schemata,  but 
in  the  light  of  the  bed-side  revelations.  The  clinical  label 
may  be  changed,  the  clinical  classification  shifted  or  re- 
placed by  a  patho-anatomical  one;  but  the  clinical  picture 
will  remain  forever. 


PART  II. 

THE  SPECIAL  FORMS  OF  INSANITY. 


Sub-order  A. 

The  Simple  Forms  not  Essentially  the  ManifesJations  of  a  Con-     u  / 
stitutional  Neurotic  Condition.  I 

First  Class:   Those    not  Associated  with    Demonstrable  Active 
Organic  Brain  Changes. 

/.  Division.  Attacking  the  Individual  Irrespective  of  the  Physiological 
Periods.  Orders:  Of  Primary  Origin  ;  Sub-order  \>:  Characterized  by  a 
fundamental  Emotional  Disturbance. 

Simple  Mania. 
Simple  Melancholia. 
Katatonia. 
Transitory  Frenzy. 


CHAPTER   I. 

Mania. 

Mania  is  a  form  of  insanity  characterized  by  an  exalted  emo- 
tional state  which  is  associated  with  a  corresponding  exaltation  of 
other  mental  and  tiervous  functions. 

The  typical  condition  of  the  maniac  *  may  be  summar- 
ized in  one  phrase:  loosening  of  the  inhibitions,  or  checks, 
both  those  of  organic  and  those  of  mental  life.  The  per- 
ceptions appear  more  acute,  the  associations  are  quick,  so 
rapid  indeed  that  the  ease  with  which  the  patient  forms 
new  and  extravagant  mental  combinations,  and  the  readi- 

*  It  is  not  necessary  to  refer  here  to  the  fact  that  this  word  has  been 
used  in  every  possible  sense,  even  in  one  equivalent  to  insanity  as  a 
whole.  In  these  pages  it  is  used  in  the  limited  sense:  that  is,  "  mania" 
without  any  qualifying  clause  refers  to  the  condition  treated  of  in  this 
chapter  alone. 


132  INSANITY. 

ness  with  which  novel  suggestions  present  themselves,  im- 
press the  novice  as  manifestations  of  a  naturally  quick  wit, 
or  of  a  talented  and  original  mind.  It  is  particularly  that 
faculty  termed  the  fancy  which  is  extraordinarily  active, 
and  the  images  crowd  each  other  in  such  profusion  that  the 
patient  in  endeavoring  to  announce  them  later  becomes 
unable  to  keep  step  with  his  words,  and  although  his  speech 
is  much  more  rapid  than  in  health  he  is  compelled  to  break 
off  in  the  middle  of  a  sentence  to  begin  the  next,  and  thus 
gives  the  superficial  impression  that  his  ideas  are  confused, 
when  in  reality  they  are  not,  at  least  in  the  earlier  periods. 
There  is  a  discrepancy  merely  between  the  rapidity  of  the 
conceptional  and  associating  transits  and  those  of  which  the 
speech  tracts  are  capable. 

Corresponding  to  the  activity  of  the  patient's  thoughts  he 
becomes  declamatory  in  style,  and  his  exaggerated  manual 
gestures  and  the  rapid  play  of  his  facial  muscles  indicate 
the  nature  of  his  disorder  as  well  as  his  spoken  words.  He 
is  not  able  to  remain  long  in  one  placej'as  it  is  impossible 
for  him  to  remain  long  silent. 

The  appetite  and  digestion  are  excellent,  the  sexual  de- 
sires increased,  the  patient  generally  feels  in  high  spirits; 
everj'thing  presented  to  his  mind  is  couleur  de  rose;  in  short 
his  whole  condition  resembles  an  intensified  sanguine  tem- 
perament. He  forgets  the  cares  and  vexations  which  may 
have  led  to  his  illness;  happy  and  contented,  it  is  his  desire 
to  make  others  so.  He  scatters  his  worldly  possessions 
among  his  friends  and  even  among  strangers;  invites  them 
to  festivals  or  to  banquets;  and  indulgences  in  drink  so 
frequently  resorted  to  in  this  condition,  like  the  venereal 
excesses  which  are  often  its  earlier  manifestations,  sometimes 
intensify  the  worst  developments  of  the  disorder. 

If  the  maniac  forgets  the  cares  and  troubles  of  this  world, 
he  becomes  equally  oblivious  of  the  restrictions  of  its  con- 
ventional and  civil  laws.  All  clogs  and  impediments  are 
swept  away  by  the  rapid  torrent  of  ideas  and  impulses 
overcrowding  and  jostling  each  other.  Reflection  has  no 
time  to  exert  its  checking  influence,  and  the  beast  in  man 
comes  to  the  surface.  Men  ordinarily  reserved  and  women 
previously  chaste  display  an  animation  in  their  looks,  an 
obscenity  in  language,  a  lasciviousness  in  gestures  and  acts, 
and  an  obliviousness  of  propriety,  shown  in  the  publicity  of 
the  latter,  which  are  among  the  most  striking  features  of 
mania. 


MANIA. 


133 


With  all  this  the  patient  is  quick  at  repartee,  defends  his 
acts  with  sarcastic  retorts,  or  explains  them  in  a  ^«<?j7-plaus- 
ible  manner.  The  removal  of  the  inhibitory  faculty  respon- 
sible for  his  violation  of  the  laws  of  decency  and  sometimes 
of  property,  also  enables  him  to  defend  those  acts,  and  un- 
fortunately for  him,  too,  suffices  to  convince  the  average 
juryman  and  sometimes  the  wearer  of  the  ermine,  that  it 
is  not  an  insane  man  but  a  clever  and  amusing  rogue  they 
have  to  deal  with;  one  who  deserves  not  only  punishment 
for  his  violation  of,  but  additional  penalties  for  his  con- 
tempt for  and  trifling  with  the  majesty  of  the  law. 

On  the  whole  the  patient  in  this  condition  greatly  resem- 
bles a  person  slightly  intoxicated.  But  just  as  the  person 
who  while  slightly  intoxicated  is  good-natured,  gener- 
ous, careless,  mischievous,  and  perhaps  lewd,  when 
more  deeply  intoxicated  becomes  irritable,  combative,  and 
incoherent;  so  the  maniac  as  his  condition  deepens  exhib- 
its a  tendency  to  angrj^  rather  than  to  pleasurable  excite- 
ment. Even  in  the  lighter  phases  it  is  noted  that  he  does 
not  bear  contradiction  well;  that  trifling  causes  produce 
undue  emotional  reaction;  that  just  as  he  laughs  without 
cause,  so  he  may  become  angry  at  an  imaginary  affront,  at  a 
mere  interruption,  or  cry  without  due  reason.  His  repro- 
duction of  impressions  and  association  of  conceptions  now 
attains  the  rapidity  of  a  delirium.  Ideas  which  were  previ- 
ously followed  out  but  not  enunciated  in  words  are  now  not 
even  followed  out  in  thought.  The  patient  is  unable  to  fix 
his  attention  long  enough  on  a  question  to  answer  it  even 
in  his  mind;  the  judgment  becomes  obtuse,  dulled  by  the 
myriad  of  conceptions  it  is  called  on  to  control.  Just  as  the 
beast  came  to  the  surface  owing  to  the  removal  of  the  conven- 
tional clogs,  egotism  now  asserts  itself  through  the  oblitera- 
eration  or  weakening  of  the  judgment.  The  patient  believes 
he  is  rich,  occupies  himself  with  rapidly  changing  projects, 
is  going  to  get  a  high  office,  or  to  sue  the  asylum  authori- 
ties for  a  large  sum  as  an  equivalent  for  his  "  wrongful  in- 
carceration." A  case  of  mania  in  piterpero  which  the  writer 
observed  at  Meynert's  clinic  in  tlie  VieniVa  asylum  exem- 
plified at  once  the  relative  acuteness  of  maniacs  and  the 
unsystematized  character  of  their  delusions.  Isolated  on 
account  of  her  violence,  -the  patient  tore  every  shred  of 
clothing  from  her  body,  and  then  in  an  incredibly  short 
space  of  time  she  picked  the  matting  of  the  isolation-room 
to  pieces,  and  made  from  the  strands  a  most  complete  and 


134  INSANITY. 

tasteful  dress,  including  every  article  of  wearing  apparel 
from  the  undergarments  to  a  cul  de  Paris,  a  bonnet,  stock- 
ings, and  a  satchel.  Ttiis  she  wore  for  a  long  period;  her 
abandonment  of  it  was  one  of  the  first  indications  of  recov- 
ery. At  the  same  time  she  loudly  asserted  that  she  was  an 
Austrian  princess;  on  being  asked  which  one  she  was  she 
gave  a  name  not  on  the  list,  and  repudiated  the  attentions 
of  an  old  deteriorated  delusional  lunatic  who  saw  in  the 
arrival  of  "  her  daughter"  at  an  asylum  the  act  of  those  con- 
spirators who  had  deprived  her,  "  the  legitimate  queen  of 
Austria,  of  her  birthright."  Later  on  she  accepted  the  re- 
lation/4but  this  was  evidently  entered  into  in  the  same 
spirit  displayed  by  children  when,  in  play  they  assume  the 
character  of  parents,  of  shopkeepers,  or  of  Santa  Claus. 
Her  manner  was  proof  of  her  insincerity,  and  she  clearly 
despised  and  pitied  her  fellow-patient. 

In  this  condition  illusions  are  frequent  and  hallucinations 
sometimes  present.  A  trivial  lesemblanceof  a  stranger  in- 
duces the  patient  to  greet  him  as  an  old  friend,  or  as  some 
important  personage  who  has  come  to  confer  an  honor  or 
to  pay  his  respects  to  him.  Like  the  mental  tone  and  the 
delusions  of  the  patient  these  disturbances  of  the  percep- 
tions are  of  a  gay  or  expansive  character;  it  is  rare  for  an 
inter-current  frightful  or  unpleasant  hallucination  to  be 
noted. 

It  is  frequently  observed — in  the  writer's  experience,  in 
about  one  third  of  the  cases — that  hallucinations  are  strik- 
ing features  of  mania  at  its  inception.  This  feature  cliar- 
acterizes  the  hallucinatory  mania  of  Mendel,  and  is  the  ordi- 
nary form  in  which  mania  from  acute  diseasesjind_puerperal 
states  manifests  itself.  In  a  case  of  this  character  under 
th^wnter's  observation — a  patient  suffering  from  mania 
in  puerpero,  who  finally  made  an  excellent  recovery  in  spite 
of  the  fact  that  she  had  no  asylum  treatment — the  first 
symptom  of  derangement  noted  was  her  taking  a  child's 
drum  and  belaboring  it  violently;  on  being  remonstrated 
with  she  tore  a  number  of  dresses  from  the  hooks  of  the 
wardrobe,  because  for  several  days — as  she  afterwards  said 
— a  disgusting  odor  had  proceeded  from  these,  which  she 
found  also  tainted  the  food  given  to  her. 

The  hallucinations  in  this  form  are  generally  present  in 
all  the  senses.  The  patients  hear  military  music,  dogs 
barking,  machinery,  or  obscene  calls;  they  see  marching 
regiments,  processions,  and    priapic    or  heavenly    visions;. 


MANIA.  135 

they  smell  noisome  or  choking  gases,  and  taste  poisonous 
or  foetid  substances  in  their  food.  But  in  so  far  as  these 
hallucinations  are  intrinsically  unpleasant  they  present 
this  contrast  with  the  similar  hallucinations  found  in  de- 
pressive forms  of  in  sanity  _iliat  the  patient  does  not  build, 
up  depressive  but  expansive  delusions  on  them.^  Halluci- 
natory mania  does  not  differ  from  ordinary  mania  except 
in  the  presence  of  the  initial  hallucinatory  period,  its 
further  progress  is  exactly  the  same. 

With  the  excitement  in  the  sensorial,  intellectual,  and  vege- 
tative spheres,  there  develops  a  corresponding  condition  of 
the  motor  apparatus.  Reference  has  already  been  made  to 
the  restlessness  and  the  declamatory  gestures,  characteris- 
tic of  mania.  These,  as  the  patient  passes  from  gay  to 
angry  excitement,  become  intensified  into  destructive  and 
violent  motor  delirium.  The  patient  vociferates  loudly  and 
incoherently,  rhymes,  yells,  and  sings  for  hours,  dances 
about  and  tears  his  clothes,  smashes  windows  and  furni- 
ture, hurls  movable  articles  out  on  the  street,  attacks  persons 
(more  rarely),  and  all  without  a  clear  motive.  The  mental 
process  becomes  more  and  more  confused  and  incoherent. 
Hallucinations  and  delusions,  the  latter  of  the  unsyste- 
mized  kind,  have  a  determining  influence  on  many  of  the 
maniac's  acts;  as  when,  for  example,  a  puerperal  maniac 
with  erotic  delusions  tears  all  her  clothing  off,  and  runs  out 
on  the  street  or  climbs  on  the  roof  to  show  her  person. 

Patients  in  this  condition,  which  is  known  as  maniacal  fury 
[furor  maniac oruni)  or  frefizy,  are  commonly  unclean,  uri- 
nating and  defecating  without  regard  to  the  surroundings, 
painting  the  walls  or  daubing  themselves  with  their  ex- 
creta,  nay  even  eating  the  latter.  These  disgusting  acts 
indicate  that  the~special  sense  perceptions,  which  appeared 
exaggerated  in  the  lighter  and  earlier  phases  of  mania,  have 
meanwhile  become  blunted. 

The  preliminary  expansive  phase  of  mania  may  be  very 
brief,  and  angry  excitement  with  pronounced  motor  ac- 
tivity may  be  continuous,  at  the  height  of  the  disorder  con- 
stituting the  Furor  of  the  Germans.  Ordinarily  furious 
and  angry  excitement  is  brief  and  recurs  episodically  in  the 
same  illness,  each  outbreak  being  separated  by  an  interval 
marked  by  the  ordinary  characters  of  mania^  or  even  having 
the  nature  of  a  lucid  intervalj^^^ 

In  a  number  of  cases  the  furious  stage  does  not  develop, 
and  hallucinations  are  absent.     The  patients  exhibit  mere- 


136  INSANITY. 

ly  the  maniacal  character:  they  are  extravagant  and  ego- 
tistical, undertake  the  fulfilment  of  projects  which  in 
themselves  may  be  quite  feasible;  but  at  the  same  time 
they  indulge  in  venereal  and  alcoholic  excesses,  visit  thea- 
tres and  balls  daily,  or  undertake  extensive  travels  merely 
for  the  sake  of  travelling.  Remonstrance  renders  them 
more  positive,  overbearing,  and  even  brutal  to  their  friends, 
and  not  rarely  leads  the  patient  into  conflicts  with  the  au- 
thorities. If  brought  face  to  face  with  his  extravagances, 
by  some  stronger  power,  he  either  denies  or  endeavors  to 
palliate  them  by  mendacious  explanations.  To  the  laity 
the  sufferer  from  this  subdued  maniacal  condition,  the  Hy- 
potnaiiia  or  mildly-developed  mania  of  Mendel,*  appears  to 
be  nothing  more  than  a  selfish,  careless,  alternately  brutal 
and  good-natured  ambitious  spendthrift.  And  this  impres- 
sion is  strengthened  when  the  patient,  on  being  sent  to  an 
asylum,  and  appreciating  his  position,  is  more  guarded  in 
his  behavior.  Often  it  is  only  the  writings  of  such  a  patient 
which  then  exhibit  his  mental  state.  Aside  from  this  the 
latter  is  expressed  in  exaggerated  ideas  of  self-importance 
in  the  abstract,  rather  than  in  formal  delusions;  in  impa- 
tience of  contradiction  and  momentary  outbreaks  of  pas- 
sion without  adequate  cause;  and  above  all  in  the  fact  that 
the  immorality,  prodigalit}',  and  morbid  egotism  of  the  sub- 
ject were  not  previously  natural  to  the  latter,  but  involved  a 
change  of  character.  The  manner  of  such  patients  is  often 
the  only  indication  of  insanity  found  at  a  single  examina- 
tion; and  repeated  examinations  may  be  necessary  to  es- 
tablish the  existence  of  the  malady. 

From  the  foregoing  it  will  appear  that  the  essential  feat- 
ure of  all  varieties  of  mania  is  the  maniacal  character;  that 
is,  the  peculiarly  mobile  and  at  the  same  time  exalted  emo- 
tional state  which  induces  in  the  patient  exaggerated  ideas 
(particularly  such  of  self-exaltation)  and  an  undue  reaction 
to  trivial  external  impressions.  Here  the  process  may  end 
in  the  lightest  cases.  In  the  typical  v^ariety  however  there 
are  superadded  word-delirium,  explosions  of  motor  vio- 
lence, and  delusions  of  a  fleeting  nature.  A  predominance 
of  hallucinations  with  these  symptoms  characterizes  hal- 


*Who  is  profoundly  in  error  in  attributing  to  Campagne  an  intention 
of  describing  this  disorder  as  an  exaggerated  egotism  under  the  term 
"  manie  raissonante,"  which  is  a  form  of  monomania  and  not  an  acute 
psychosis. 


MANIA.  137 

lucinatory  mania,  and  a  greater  intensity  and  longer  dura- 
tion of  the  furious  phases  is  the  feature  of  furious  mania. 
At  bottom  they  are  all  one  and  the  same  disorder,  which, 
however  much  it  varies  in  the  intensity  and  direction  of  its 
symptoms,  does  not  lose  the  essential  characters  predicated 
above. 

The  outbreak  of  mania  is  rarely  if  ever  sudden  or 
rapid.  This  is  the  case  in  mania  occurring  in  hysterical  sub- 
jects. In  the  hallucinatory  variety  the  incubation  of  the 
disorder  may  be  apparently  restricted  to  a  few  days;  and 
it  seems  as  if  the  hallucinatory  state  which  precedes  the 
outbreak  of  the  characteristic  maniacal  symptoms  takes 
the  place  of  the  ordinarily  prolonged  prodromal  period  of 
typical  mania. 

In  typical  mania  there  is  commonly  observed,  from  one 
to  three  months  prior  to  the  maniacal  explosion,  a  de- 
pressed mental  and  somatic  state.  Gastric  disturbances 
are  early  noted,  the  tongue  is  furred,  the  bowels  consti- 
pated; anorexia,  a  sense  of  tension  in  the  head,  particu- 
larly intensified  over  the  eyes  and  at  the  back  of  the 
head,  and  probably  like  the  concomitant  insomnia  related 
to  the  visceral  disturbance,  are  commonly  present.  With 
this  the  patient  experiences  an  inability  to  concentrate  his 
thoughts;  it  is  with  difficulty  that  he  is  able  to  carry  out  his 
duties,  he  feels  physically  and  mentally  prostrated,  and  in 
his  endeavor  to  account  for  his  condition  becomes  hypo- 
chondriacal, refers  his  weakened  condition  to  early  ex- 
cesses, or,  if  of  a  devout  turn  of  mind,  attributes  the 
"punishment"  to  some  early  "sin."  At  the  same  time  he 
struggles  against  his  frailty,  he  attends  to  his  duties,  how- 
ever great  the  effort,  thus  intensifying  the  causes  of  his 
disorderjand  may  still  pass  for  nothing  more  than  a  dys- 
peptic, (indeed  there  is  no  clinical  difference  between  the  j 
condition  of  many  dyspeptics  who  never  become  maniacal  I  ID 
and  of  some  maniacs  in  the  prodromal  stage  of  their  disorder.  |  \ 
It  is  only  very  exceptionally  and  then  not  in  uncomplicated 
cases  that  the  depression  preceding  the  maniacal  period 
reaches  the  degree  of  a  genuine  melancholia;  and  nothing 
could  be  more  improper  than  to  designate  the  initial 
period  of  mania  its  "  melancholic  stage,"  as  some  English 
and  German  writers  do.  The  fundamental  feature  of  mel- 
ancholia (see  next  chapter)  is,  with  the  rare  exceptions  al- 
luded to,  absent. 

The  transition  from  the  initial  stage  of  depression  to  the 


138  INSANITY. 

maniacal  culmination  is  gradual.  The  appetite  returns, 
the  sleep  improves,  the  mental  condition  appears  normal, 
and  to  all  appearances  the  patient  seems  healthy  and  con- 
gratulates himself  on  his  recovery  from  what  he  and  his 
relatives  have  regarded  as  a  simple  attack  of  nervous  pros- 
tration. But  after  a  few  days  or  weeks  his  subjective  feel- 
ing of  well-being  assumes  an  exaggerated  tinge,  and  the 
exalted  emotional  stage  rapidly  growing  out  of  it  inaugu- 
rates that  true  maniacal  condition  whose  features  were 
detailed  at  the  beginning  of  this  chapter. 

Tlie  DURATION  OF  MANIA  varics.  An  average  case  of 
typical  mania  will  exhdbit  an  initial  stage  of  depression 
lasting  about  six  weeks,  a  maniacal  period  of  about  three 
months,  while  the  period  of  convalescence  will  occupy  about 
a  fortnight.  The  average  total  duration  of  the  illness  in  a 
case  of  moderate  severity  may  be  therefore  placed  at  or 
about  the  period  of  five  months.  But  very  ^tense  cases 
may  exceptionally  last  but  a  few  weeks,  and  very  ^ild  ones 
may  similarly  last  a  year  or  over.  Such  have  been  report- 
ed in  which  recovery  took  place  after  the  disorder  had 
lasted  a  year  and  a  half. 

Frequency  and  Prognosis. — Of  5,481  admissions  to  the 
Bicetre,  reported  by  Marce,  779  were  of  cases  of  mania, 
300  being  males  and  479  females.  The  greater  frequency 
of  admissions  of  females  to  public  asylums  is  attributable 
to  the  large  proportion  of  females  in  the  poorer  classes  be- 
coming insane  in  the  puerperal  state,  owing  to  the  com- 
bined influence  of  physical  causes:  deprivation  of  food, 
rapid  succession  of  childbirths,  and  alcoholic  excesses; 
and  unfavorable  mental  influences:  seduction,  abandon- 
ment, domestic  cares,  and  neglect  by  the  husband.  The 
same  disproportion  of  the  sexes  is  not  found  among  the 
wealthy.  In  the  consultation  practice  of  the  writer  mania 
exhibits  an  equal  percentage  in  both  sexes,  and  in  both 
plays  a  less  prominent  part  than  in  the  public  asylum  sta- 
tistics. Of  2,297  insane  males  admitted  to  the  New  York 
Pauper  Insane  Asylum,  and  tabulated  by  the  writer,  260 
were  affected  with  simple  mania,  or  a  little  over  eleven  per 
cent.* 

Mania  is  more  frequent  between  the  25th  and  35th  year 
in  males,  owing  to  the  greater  frequency  of  alcoliolic  indul- 
gences and  venereal  excesses  at  this  period,  coupled  with  the 

*  Race  and  Insanity,  Journal  of  Nervous  ami  I^Ienial  Diseases.     1880, 


MANIA. 


139 


fact  that  at  this  period  of  life  there  is  a  greater  disposition 
to  disorders  of  an  active  type  than  at  any  other. 

The  prognosis  of  mania  is  very  favorable,  in  fact,  more  so 
than  that  oi  all  '^other  psychoses,  with  the  exception  of 
stuporous,  confusional^/and  transitory  insanity.  Various 
authors  estimate  theTecbveries  at  from  sixty  to  eighty  per 
hundred;  the  latter  figure  accords  with  the  writer's  experi- 
ence. Partial  recoveries  are  also  noted,  where  the  patient 
ceases  to  be  maniacal,  but  exhibits  an  undue  excitability 
and  a  permanent  enfeeblement  of  the  judgment  and  mem- 
ory. Those  patients  who  do  not  recover  either  pass  into 
so-called  chronic  mania  with  confusion  of  ideas,  and  thence 
to  terminal  dementia,  or  directly  and  gradually  into  this 
latter  condition.  From  two  to  five  cases  out  of  the  hun- 
dred terminate  fatally,  either  through  the  somatic  disorder, 
such  as  the  fever,  or  the  puerperal  state  from  which  the 
mania  originated,  or  by  complicating  disorders  like  pneu- 
monia, developed  in  consequence  of  exposure  and  alco- 
holic excesses,  or  finally  through  maniacal  exhaustion. 

It  is  rare  for  mania  to  terminate  by  a  crisis;  cases  have 
been  observed  where  the  formation  of  an  abscess,  or  a 
diarrhoea,  has  been  instantly  followed  by  amelioration,  just 
as  complementarily,  in  an  instance  within  the  writer's  ob- 
servation, the  healing  of  a  varicose  ulcer  was  followed  by 
a  maniacal  condition.  Ordinarily  convalescence  takes 
place  slowly,  and  is  marked  by  numerous  ups  and  downs. 
The  occurrence  of  brief  lucid  periods  is  the  first  indication 
of  returning  health.  The  patient  either  admits  that  he  has 
acted  in  an  improper  manner,  apologizes  for  his  misconduct, 
or  more  frequently  becomes  taciturn,  and  unwilling  to 
make  a  humiliating  confession.*  The  next  hour  or  the  next 
day  may  see  him  exalted  and  violent  again.  But  the  lucid 
periods  recur,  they  become  more  and  more  frequent,  and  of 
longer  duration,  until  they  run  into  each  other,  and  the 
healthy  state  is  definitely  re-established.  The  lucid  periods 
may  be  marked  by  a  sort  of  reactionary  depression,  but 
this  is  rather  a  favorable  than  an  unfavorable  sign. 

A  patient  who  has  completely  recovered  from  an  attack 
of  acute  mania  is  not  usually  liable  to  a  recurrence  of  the 
disease.  A  repetition  of  the  injurious  influences  which 
produced  the  first  attack  may,  however,  lead  to  repetitions 
of  the   maniacal   attacks,   particularly  where    there    is   an 

*  Which  is  a  most  favorable  indication. 


I40  INSANITY. 

hereditary  predisposition.  Such  attacks  are  as  strictly  to 
be  considered  attacks  of  simple  mania  as  the  first  attack, 
and  do  not  justify  the  erection  of  a  special  form  of  in- 
sanity, designated  as  "  recurrent  mania." 


CHAPTER    II. 

Melancholia. 


Melancholia  is  a  form  of  insanity  whose  essential  and  charac- 
teristic feature  is  a  depressed,  i.e.,  subjectively  arising  painful 
emotional  state,  which  may  be  associated  with  a  depression  of 
other  nervous  functions. 

At  its  height  the  melancholic  disorder  is  the  antithesis  of 
the  maniacal.  Just  as  every  gesture  and  every  thought  of 
the  maniac  betrays  his  exalted  emotional  state,  so  the  atti- 
tude and  expression  of  the  melancholiac,  his  thoughts,  and 
his  delusions,  illusions,  and  hallucinations — if  he  have 
these — announce  the  dominant  emotion  of  sadness  or  psy- 
chical pain.  While  the  typical  maniac  shows  a  tendency  to 
restless  mobility,  the  typical  melancholiac  exhibits  a  tenden- 
cy to  motor  stagnation.  While  the  maniac  is  aggressive, 
communicative,  and  obtrusive,  the  melancholiac  is  glad  to 
be  let  alone.  While  the  somatic  functions  appear  to  be  ex- 
alted in  mania,  they  share  in  the  universal  depression  in 
melancholia:  the  melancholic  patient  refuses  food,  where 
the  maniac  is  bulimic*  While  the  maniac  indulges  in  am- 
bitious schemes,  or  gives  himself  up  to  self-satisfied  con- 
templation of  his  excellent  physical,  financial,  and  social 
condition,  the  melancholiac  is  overwhelmed  by  his  physical 
worthlessness,  his  moral  turpitude,  terrible  anticipations  of 
the  future,  and  he  consequently  contemplates,  if  he  does 
not  commit,  suicide.  While  the  memory  appears  more 
acute,  and  the  conceptions  are  associated  with  delirious 
rapidity  in  mania,  the  former  is  clouded,  and  the  reproduc- 
tion and  association  of  conceptions  are  retarded  in  melan- 
cholia.    In   short,  while  in  mania  the  typical  state  is    in- 

*  Bulimia  is  a  term  applied  to  excessive  and  rapacious  appetite  in  the 
insane.  It  is,  unfortunately,  ranked  by  some  among  the  morbid  propen- 
sities. 


MELANCHOLIA.  I4I 

aagurated  by  a  subjectively  arising  emotional  exaltation, 
which  leads  to  a  suspension  of  the  inhibitions,  we  have 
the  reverse  emotional  state  in  melancholia,  leading  to  an 
intensification  of  these  very  inhibitions. 

While  the  common  basis  on  which  the  symptoms  in  all 
melancholiacs  develop  is  the  subjective  painful  emotion, 
and  all  melancholiacs  are  consequently  sad,  depressed,  dis- 
satisfied, and  isolate  themselves  from,  or  become  reserved 
and  perhaps  inimical  to,  their  surroundings;  more  positive 
symptoms  grow  out  of  this  fundamental  state  in  most  cases. 

The  commonest  of  these  symptoms  are  iifisystoiiatizcd  de- 
lusions of  a  depressive  nature.  The  patient  endeavoring  to  ac- 
count to  himself  for  his  painful  emotional  state,  unable  to 
understand  why  his  affection  for  his  relatives  and  friends 
has  ceased  or  diminished,  or  seeking  in  the  outer  world  for 
some  inimical  agent  responsible  for  his  depression,  con- 
cludes that  he  is  threatened  with  bankruptcy,  that  he  has 
been  a  bad  husband,  or  that  he  has  been  remiss  to  his  Crea- 
tor in  some  way  not  clear  to  him.  From  these  vague  no- 
tions there  is  but  a  step  to  positive  delusions.  The  patient 
may  believe  himself  the  subject  of  persecution  by  diaboli- 
cal or  human  agencies,  or  by  witclies.  These,  he  believes, 
attack  either  his  person  or  his  fortune,  and  threaten  his 
family,  and  not  unfrequentiy  the  melancholiac,  to  the  sui- 
cide to  which  he  resorts  for  the  purpose  of  escaping  his 
personal  foes,  adds  the  murder  of  his  family,  to  save  them 
from  the  sadder  fate  which  his  delusions  conjure  up  for 
them. 

Sometimes  an  insignificant  crime,  or  an  entirely  imagi- 
nary one,  induces  the  patient  to  consider  his  sufferings  as  a 
just  retribution  for  his  misdeeds.  He  may  even  go  to 
court  to  confess  real  or  imaginary  offences  committed  many 
years  before  ;  and  deserving,  as  he  believes  himself  to  be, 
of  capital  punishment,  he  may,  in  order  to  accomplish  his 
merited  doom,  kill  another  person.  Homicides  are  also  re- 
sorted to  by  melancholiacs,  in  order  to  gratify  their  suicidal 
inclinations,  on  the  one  hand,  without  conflicting  with  the 
religious  interdiction  of  that  crime,  on  the  other. 

The  delusions  of  the  melancholiac  may  be  modified  by 
sensory  disturbances  of  central  orgin,  such  as  neuralgias, 
anaesthesias,  or  disordered  smell  and  taste.  In  this  event 
hypochondriacal  delusions  are  apt  to  arise,  as  such  of  being 
poisoned  or  annoyed  by  irritant  and  noisome  vapors  and 
gases. 


142  INSANITY. 

Hallucinations  are  very  frequent  in  melancholia,  and 
while  they  are  usually  secondary  to  the  delusions  and  par- 
take of  their  formal  character,  they  serve  to  fortify  and 
elaborate  them.  A  melancholiac  who  thinks  that  he  is  per- 
secuted by  diabolical  forces  sees  the  devil  and  his  imps, 
hears  the  roaring  flames  of  hell-fire,  and  smells  brimstone. 
He  who  imagines  himself  guilty  of  a  crime  sees  the 
corpses  of  those  he  has  killed,  the  ruin  of  those  he  has 
cheated,  the  girl  he  has  betrayed,  and  the  officers  of  the 
law  who  are  on  his  track.  He  who  is  pursued  by  enemies 
hears  taunting  and  insulting  voices,  indictments  read 
against  his  person,  attachments  against  his  property,  and 
orders  of  arrest.  Finally  he  sees  the  jailer,  the  hangman, 
and  the  scaffold.  The  melancholiac  who  suffers  from  de- 
lusions of  a  hypochondriacal  tinge  is  tortured  by  a  thou- 
sand imps,  who  run  needles  into  his  flesh,  by  powerful 
electric  batteries,  or  by  some  animal  or  person  introduced 
into  his  body. 

With  such  overwhelming  pictures  of  terror  arising  in  the 
patient's  mind,  it  is  not  strange  that  while  the  general  con- 
dition of  the  melancholiac  is  abulic  and  passive,  in  some 
cases  and  at  some  stages  of  the  disorder  the  patient  should 
become  restless  from  fear,  and  wander  around  seeking  for 
redress  and  relief  in  a  vague  way.  In  some  cases,  and  then 
at  the  height  of  the  disorder,  spurious  states  of  fury  may 
be  developed,  states  which  by  the  uninitiated  are  fre- 
quently called  "  melancholic  mania."  The  consciousness 
seems  to  be  nearly  obliterated  during  these  spells,  in  vague 
fright  the  patient  raves  that  the  world  is  destroyed,  that  all 
is  lost,  a  nameless  terror  seizes  on  him,  and  in  blind  disre- 
gard of  consequences  he  destroys  or  attacks  everything 
within  reach.  He  tears  his  clothes,  murders,  commits  sui- 
cide, or  destroys  the  furniture  and  resorts  to  self-mutilation. 
Cases  are  on  record  where  patients  in  this  condition  have 
torn  out  their  eyes,  cut  open  the  scrotum,  disembowelled 
themselves,  have  thrown  themselves  into  the  fire  or  against 
the  cages  in  which  wild  animals  were  confined.  In  one 
instance  a  patient  who  had  been  sent  to  an  asylum  on  the 
recommendation  of  the  writer — but,  unfortunately,  to  an  in- 
stitution conducted  as  a  sort  of  private  side-venture  by  the 
authorities  of  a  large  pauper  institution — after  having 
cut  herself  with  the  fragments  of  a  broken  pane  of  glass,  and 
thus  sufficiently  warned  her  supervisors  of  the  dangerous 
tendencies  of  her  frenz}'-,  took  a  rather  blunt  stick  of  wood, 


MELANCHOLIA.  I43 

and  ran  it  into  her  abdomen,  ripping  it  up  to  a  terrible  ex- 
tent. 

These  spells  differ  from  the  fury  of  the  maniac  in  that 
the  delirium  if  present  is  never  expansive  nor  as  multi- 
farious, and  that  the  violent  acts  are  as  apt  to  be  directed 
against  the  patient  himself  as  against  others.  Conscious- 
ness is  not  affected  in  the  same  way  in  the  two  states.  In 
maniacal  fury  it  is  confused  rather  than  obliterated;  in  the 
violent  outbreaks  of  melancholia,  it  is  rather  obscured  or 
obliterated  than  confused.  In  mania  the  outbreak  is  the  re- 
sult of  an  expansive  or  angry  emotion;  in  melancholia  the 
outbreak,  best  known  as  melancholic  frenzy  {j-aptus  melan- 
.cholicus),  is  the  outcome  of  an  anxious  terror. 

In  those  cases  which  are  characterized  by  inter-current 
attacks  of  melancholic  frenzy  the  fright  immediately  pre- 
ceding it  is  usually  associated  with  anxious  precordial  sen- 
sations, and  these,  summarized  under  the  term  precordial 
fright,  are  supposed  to  depend  on  some  disturbance  of  the 
pneum.ogastric  and  the  sympathetic  centres.  This  view  is 
■borne  out  by  the  fact  that  the  pulse  is  frequent,  irregular, 
and  small,  the  bodily  surface  pale  and  cold,  while  the  breath- 
ing is  superficial  and  the  secretions  are  suppressed. 

Frenzy  is  particularly  apt  to  occur  in  melancholia  devel- 
oping in  alcoholic  subjects,  owing  to  the  predominance  of 
multitudinous  and  friglatful  hallucinations,  panphobia,  and 
precordial  fright  in  such  patients.* 

Melancholic  frenzy  is  of  shorter  duration  than  maniacal 
furor,  and  unlike  the  latter  it  terminates  suddenly.  The  pa- 
tient appears  as  if  relieved  by  the  explosion,  the  fright  is 
gone,  and  he  awakes  as  from  a  dream  of  which  he  has  but 
an  obscure  if  any  recollection.  The  condition  is  merely  an 
episode  of  melancholia,  as  the  outbreaks  of  furor  are 
episodes  of  mania,  and  does  not  justify  the  erection  of  a 
•distinct  form  of  melancholia. 

There  is  not  as  some  have  claimed  a  pulse  character  pe- 
culiar to  melancholia;  that  found  with  frenzy  has  just  been 
described;  a  different  vaso-motor  condition  is  found  in  me- 
lancholia with  stupor.  Here  the  entire  muscular  system  ap- 
pears to  be  in  a  condition  of  spasm,  which  is  shared  by  the 

*  "  Alcoholic  melancholia"  is  a  term  applied  to  melancholia  occurring 
in  inebriates.  Usually  some  of  the  ordinary  causes  of  melancholia  are 
superadded;  it  is  remarkable  for  its  brief  duration  and  favorable  prog- 
nosis. 


144  INSANITY. 

muscular  coats  of  the  arteries,  so  tliat    we  have  vascular 
spasm  as  well. 

Other  of  the  more  common  disturbances  in  melancholia 
are  feelings  of  tension  or  of  emptiness  in  the  head.  Dis- 
ordered tactile  and  thermic  sensations,  so  frequenth^  serving 
as  the  basis  of  delusions,  as  above  stated,  are  found  in  all 
the  more  severe  cases.  In  addition,  refusal  of  food  is  a  char- 
acteristic feature  with  the  vast  majority  of  melancholiacs, 
and  may  have  two  different  sources.  It  is  either  due  to 
the  anorexia  which  is  an  expression  of  the  generally  ady- 
namic state  of  the  system,  or  it  is  due  to  delusions  that 
the  food  is  poisoned,  or  that  the  sufferer  is  not  worthy  to 
eat.  Anaemia  is  found  in  the  larger  number  of  patients 
from  the  inception  of  the  disorder;  in  all  severe  cases  it  be- 
comes marked  as  the  disease  advances.  In  a  single  case  of 
mild  melancliolia  in  the  writer's  observation  it  was  absent. 
There  seems  to  be  some  obscure  source  for  the  general  nu- 
tritive disturbance  in  melancholia,  for  thelossin  weight  and 
the  rapid  wasting,  particularly  noticeable  in  the  face,  and 
giving  the  latter  a  pinched  appearance  or  one  of  premature 
age,  seem  to  be  out  of  all  proportion  to  what  one  would  ex- 
pect as  a  result  of  the  refusal  and  insufficient  assimilation 
of  food. 

As  in  mania,  there  are  a  number  of  varieties  also  in  me- 
lancholia, which,  as  in  the  case  of  the  varieties  of  mania, 
however  great  the  difference  between  them  as  to  the  inten- 
sity and  direction  of  the  symptoms,  have  the  fundamental 
character  of  melancholia,  the  depressed  emotional  state,  as 
a  common  and  as  their  essential  feature. 

The  ordinary  form  of  melancholia  has  been  just  de- 
scribed. When  the  patient,  instead  of  remaining  impassive, 
becomes  restless  under  the  influence  of  delusions,  halluci- 
nations, or  anxious  feelings,  and  runs  around  wringing 
his  hands,  weeping  and  crying  out  against  his  persecutors, 
the  wicked  world,  or  a  remorseless  fate,  he  is  said  to  be  suf- 
fering from  active  melancholia  {^melancholia  agitata).  It  is 
the  episodial  intensification  of  this  condition,  an  intensifi- 
cation which  reaches  such  a  degree  as  to  overwhelm  the 
patient's  consciousness,  that  constitutes  the  melancholic 
frenz3^  alluded  to  above. 

While  the  subjective  fears  and  beliefs  of  the  melancholiac 
in  these  cases  lead  to  restlessness,  in  others  the  influence 
of  delusions  and  other  factors  is  of  so  overwhelming  a  char- 
acter as  to  throw  the  patient  into  a  state  of  stupor.      The 


MELANCHOLIA.  I45 

patient  sits  motionless,  and  his  flexor  muscles  exert  their 
preponderating  influence  over  the  extensors.  The  head  is 
bent  forward,  the  knees  and  the  elbows  flexed,  and  the  ten- 
sion may  involve  the  facial  muscles,  giving  the  face  a  re- 
markably frozen  and  tetanic  expression.  It  has  been  even 
claimed  that  in  some  cases  a  true  cataleptic  waxy  flexibility 
of  the  extremities  may  be  found.  In  addition  the  patient 
is  mute,  his  breathing  is  slow  and  superficial,  the  temper- 
ature sinks,  the  extremities  are  cold  and  blue,  and  the 
physiological  discharges  are  suppressed  or  diminished. 

The  pulse  is  frequent  in  this  condition,  while  it  is  ordi- 
narily slow  in  melancholia;  but,  as  in  melancholia  generally, 
the  arterial  tension  is  greatly  increased,  the  radials  feeling 
almost  wiry  under  the  finger. 

Constipation,  so  common  in  all  forms  of  melancholia,  is 
extreme  in  the  atonic  form,  and  the  nutritive  disturbance 
generally  is  most  marked  in  melancholia  with  stupor  [melan- 
cholia atto?iita),  as  this  variety  is  termed.  That  it  is  merely 
a  variety  of  melancholia  is  shown  by  the  fact  that  it  may 
alternate  with  agitated  as  well  as  with  typical  melancholia, 
and  may  be  interrupted  like  the  other  forms  by  outbreaks 
of  melancholic  frenzy.  These  are  usually  provoked  by  dis- 
turbing the  patient,  as  when  endeavoring  to  move  him,  or 
to  compel  him  to  take  food.  A  second  series  of  facts, 
proving  that  melancholia  attonita  is  a  true  melancholia,  and 
not  a  condition  of  simple  neural  anenergy,  is  derived  from 
the  recollections  of  patients  recovering  from  this  condition. 
Under  all  circumstances  the  patients  have  a  certain  degree 
of  consciousness  :  immobile  and  masklike  as  the  features 
seem,  an  occasional  flicker  of  an  expression  passing  across 
the  face  indicates  the  persistence  of  mental  life.  On  recov- 
ering they  report  having  had  distinct  and  horrible  phan- 
tasms, hallucinations  far  exceeding  in  their  terrible  charac- 
ter those  found  with  ordinary  melancholia.  The  most 
frightful  tortures,  massacre  of  their  best  friends,  with  whose 
blood  the  food  given  to  the  patient  is  supposed  to  be  sea- 
soned, devouring  of  their  flesh  by  myriads  of  foul  beasts, 
are  witnessed,  and  fearful  imprecations  heard  by  them;  so 
that  the  frozen  attitude  and  expression  appear  to  be  the 
expression  of  a  fear  and  dread  so  intense  that  the  patient  is, 
as  it  were,  struck  dumb  and  paralyzed  by  them.  It  is  hence 
not  improperly  styled  thunderstruck  melancholia  (angedon- 
nerte  Melancholic^  by  the  Germans. 

Just  as  there  is  a  form  of  mania   in  which  the   maniacal 


146  INSANITY. 

outbursts  may  be  but  feebly  marked,  and  the  delirium,  in- 
coherency,  and  hallucinations  absent,  so  there  is  a  form  of 
melancholia  in  which  there  are  no  delusions,  no  hallucina- 
tions, and  neither  stupor  nor  restlessness.  Just  as  the  form 
of  mania  lacking  the  more  violent  symptoms  is  marked  ex- 
clusively by  the  development  of  the  maniacal  character,  so 
there  is  a  form  of  melancholia  whose  sole  discoverable 
morbid  feature  is  the  melancholic  character;  and  as  the 
former  has  been  termed  a  hypo-mania  by  Mendel,  the  latter 
might  be  termed  a  hypo-melancholia.  It  is  sometimes 
designated  "  reasoning  melancholia,"  and  better  still  as 
melancholia  sine  delirio. 

Much  has  been  recently  written  about  the  treatment  of 
patients  suffering  from  this  mild  melancholia  at  home; 
and  it  is  true  that  a  number  are  there  treated  and  recover. 
But,  in  using  the  adjective  "  mild,"  let  it  be  distinctly 
understood  that  this  form  is  far  more  dangerous  as  to  its 
possible  civil  and  criminal  consequences  than  any  other, 
and  that  the  risk  assumed  by  those  who  attempt  to  treat  a 
patient  suffering  from  this  form  outside  of  the  walls  of  an 
institution  is  a  grave  one.  It  is  not  the  insidiousness  of 
the  malady — and  it  is  very  insidious  indeed — that  alone 
makes  it  so  dangerous  a  one,  but  the  fact  that  the  reasoning 
powers  of  the  patient  are  relativeh'  intact,  and  permit  him 
to  carry  out  his  schemes  of  homicide  and  suicide  with  a 
cunning  and  a  deliberation  which  could  not  be  exceeded  by 
a  person  in  the  full  enjoyment  of  mental  health.  Another 
element  of  danger  is  the  great  likelihood  of  such  patients 
developing  morbid  impulses.  The  sight  of  a  weapon,  in 
their  subjectively  painful  emotional  state,  suggests  its  use; 
the  sight  of  a  real  or  supposed  foe  determines  an  assault ; 
the  reading  of  accounts  of  an}^  novel  method  of  suicide  or 
homicide,  or  the  spectacle  of  an  execution,  suggests  imita- 
tion; the  sight  of  the  patient's  children  suggests  the  desira- 
bility of  removing  them  from  a  world  which  holds  out  but 
a  hopeless  vista  of  gloom  to  the  patient's  mind.  The  fre- 
quent immolation  of  a  family  by  one  of  its  members  is 
ordinarily  the  deed  of  a  melancholiac  suffering  from  this 
form  of  mental  disorder,  and  a  large  proportion  of  suicides 
generally  are  referable  to  the  same  cause.  A  downcast  ex- 
pression of  countenance,  a  frequent  recurrence  of  causeless 
fits  of  depression,  frequent  sighing,  or  perhaps  groaning, 
possibly  dilated  pupils,  and  a  contracted  condition  of  the 
arteries,  may  be   the  sole   but  sufficient  indications  to  the 


MELANCHOLIA.  147- 

experienced  physician,  warning  him  of  the  danger  ahead, 
while  to  the  uninitiated,  or  the  over-confident,  the  condition 
appears  to  be  merely  a  "  fit  of  the  blues." 

There  is  not  that  contrast  between  the  initial  stage  of 
MELANCHOLIA  and  the  fully-developed  phase  of  the  disorder 
which  we  find  in  mania.  The  various  symptoms  detailed 
appear,  as  a  rule,  gradually,  after  a  preliminary  period,  dur- 
ing which  the  patient  complains  of  an  inability  to  exert  his 
will,  of  a  mental  vacuum,  of  impairment  of  the  memory, 
and  of  the  other  signs  just  noticed  as  comprising  the  pic- 
ture of  melancholia  without  delirium.  It  is  only  in  the 
melancholia  following  fevers,  exhausting  discharges,  and 
sudden  emotional  shocks  that  the  symptoms  rapidly  or 
suddenly  attain  their  maximum. 

The  DURATION  OF  MELANCHOLIA  may  comprise  weeks, 
months,  or  years.  Its  average  duration  is  from  three  to 
eight  months. 

The  FREQUENCY  OF  MELANCHOLIA  it  is  difficult  to  deter- 
mine, as  a  large  number  of  the  patients  never  reach  the 
asylum,  and  recover,  die,  or  commit  suicide  outside  its 
walls.  Of  2,297  admissions  to  the  pauper  insane  asylum  for 
males,  of  New  York  city,  301,  or  a  little  over  thirteen  per 
cent,  were  cases  of  melancholia.  Of  1,193  patients  of  both 
sexes  admitted  to  the  reception  wards  of  Professor  Mey- 
nert,  not  quite  six  per  cent  were  melancholiacs.  The  greater 
frequency  of  melancholia  with  females,  which  is  in  part  attri- 
butable to  the  influence  of  prolonged  lactation,  pregnancy, 
exhausting  discharges,  and  chloro-anaemia  in  provoking 
this  psychosis,  is  illustrated  by  the  statistics  of  the  Buda- 
Pesth  asylum.  Here  ten  per  cent  of  the  male  and  seventeen 
per  cent  of  the  female  patients  suffered  from  melancholia. 
Of  146  males  received  at  Feldhof  by  Krafft-Ebing,  thirteen, 
or  nearly  seven  per  cent,  were  melancholiacs  ;  while  of  121 
females  eighteen,  or  nearly  fifteen  per  cent,  suffered  from 
the  same  disease.  In  the  writer's  statistics  the  striking 
fact  is  noticeable,  that  melancholia  is  most  freq'ient  in 
the  Teutonic  peoples,  the  ones  who,  according  to  Morselli, 
also  show  the  highest  suicidal  ratio;  and  among  these  it 
was  found  more  frequent  with  those  who  had  emigrated, 
than  with  those  who  had  been  born  in  this  country.  This 
illustrates  the  effect  of  nostalgia  in  producing  melancholia, 
at  least  in  part,  an  effect  which  has  been  observed  among 
the  Bavarian  soldiers  recruited  from  the  mountain  districts, 
of  the  country. 


148  INSANITY. 

In  private  practice  melancholia,  particularly  of  the  lighter 
grades,  is  very  common;  and  is  not  unfrequently  treated 
as  "  neuraesthenia" — whatever  that  mayor  may  not  be — 
and  dyspepsia,  and,  thanks  to  the  self-limiting  tendency  of 
the  lighter  forms  of  the  psychosis,  it  is  frequently  cured  on 
either  theory. 

The  prognosis  of  melancholia  is  less  favorable  than 
that  of  mania,  about  six  out  of  ten  patients  recovering 
completely.  The  proportion  of  cured  females  is  much 
greater  than  that  of  cured  males;  this  is  due  to  the  fact 
that  the  removable  causes — those  of  a  purely  physical 
character — are  relatively  more  frequent  in  the  etiology  of 
melancholia  in  females;  while  the  therapeutical  measures 
less  accessible,  cerebral  overstrain,  and  business  troubles  are 
more  frequent  in  males.  The  prognosis  is  considered  to  be 
more  favorable  in  the  young  than  in  the  old,  and  in  cases 
not  presenting  an  hereditary  taint  ;  this  is  not,  however, 
strictly  true:  melancholiacs  with  an  hereditary  tendency  re- 
cover as  frequently,  and  sometimes  more  rapidly,  than  those 
whose  hereditary  history  is  good;  but  thedanger  lies  in  the 
more  frequent  development  of  niclanchoUa  sine  dclirio  in 
hereditary  cases  — with  all  its  attendant  dangers  as  to  sui- 
cide and  homicide. 

Aside  from  the  greater  likelihood  of  suicide  in  melancholia 
sine  dclirio,  as  well  as  the  probability  of  recurrence,  the 
immediate  prognosis  of  this  variety  is  always  favorable. 
It  is  next  most  favorable  in  the  typical  and  the  agitated 
forms,  over  eighty  per  cent  of  the  patients  suffering  from 
these  presenting  good  prospects  as  to  recovery,  under 
early  and  proper  treatment.  With  stupid  or  atonic  melan- 
cholia the  outlook  is  bad,  and  although  the  patients  may 
in  exceptional  cases  recover  wnth  apparent  suddenness, 
the  larger  number  recover  slowly  or  not  at  all,  and 
then  die  of  inter-current  affections  or  pass  into  terminal 
dementia.  Among  the  causes  of  death  are  mal-nutrition, 
diarrhoea,  and  catarrhal  as  well  as  tubercular  phthisis  ;  the 
latter  form  of  pulmonary  trouble  is  particularly  frequent. 
Summarizing  the  prognostic  indications,  these  may  be 
enumerated  in  the  following  order  of  importance  :  The 
prognosis  is  more  favorable  according  as  there  is  less 
stupor,  less  nutritive  disturbance,  more  variation  in  the 
symptoms  from  day  to  day,  and  with  youth  and  the  female 
sex.  It  is  of  specially  good  import  in  melancholia  when 
the  patient's  condition  shows  a  marked  improvement  from 


KATATONIC   INSANITY.  I49 

evening  to  evening.  As  a  rule  melancholiacs  are  worse  in 
the  morning  than  in  the  later  part  of  the  day.  It  seems 
as  if  the  irritant  effect  of  the  diurnal  routine,  and  perhaps 
the  better  nutrition  enforced  in  the  waking  state,  lead  to  a 
gradual  amelioration  of  the  vaso-motor  disturbance,  which 
is  at  the  basis  of  ijie  precordial  fright,  and  the  resulting 
delusions  and  frenzy.  It  has  been  noted  as  a  confirmation 
of  this  view  that  the  administration  of  cardiac  and  general 
stimulants,  as  well  as  easily  assimilable  food,  whenever  the 
patient  awakes  at  night,  is  followed  by  sleep  and  an  im- 
provement lasting  throughout  the  following  day. 

When  melancholia  does  not  terminate  in  recovery  or 
death,  it  passes  either  into  terminal  dementia  of  the  apa- 
thetic variety — which,  as  above  stated,  is  a  common  sequel 
of  melancholic  attonita — or  into  a  chronic  delusional  insanity 
with  deterioration — an  occasional  sequel  of  the  typical,  and 
a  more  frequent  one  of  the  agitated  forms. 


CHAPTER   III. 

Katatonic  Insanity, 


Katatonia  is  a  form  of  insanity  characterized  by  a  pathetical 
emotional  state  and  verbigeration,  combined  with  a  condition  of 
motor  tension. 

This  well-marked  though  not  generally  recognized  men- 
tal disorder  was  first  demarcated  by  Kahlbaum  of  Gorlitz 
about  eight  years  ago.  In  the  course  of  the  writer's  study 
of  the  pauper  insane  at  Ward's  Island  he  became  impressed 
with  the  genuineness  of  the  grounds  on  which  Kahlbaum 
based  this  classification;  and  the  subsequently  published 
and  more  recently  reprinted  paper  of  Kiernan,  based  on  a 
study  of  the  same  patients,  was  the  first  confirmation  of  the 
important  and  practical  proposition  of  the  Prussian  alienist. 

The  illness  begins  with  an  initial  stage  resembling  that 
of  any  ordinary  melancholia.  This  is  followed  by  a  period 
in  which  the  patient  presents  an  almost  cyclical  alternation 
of  atony,  excitement  of  a  peculiar  type,  confusion  and 
depression,  which  finally  merge  into  a  state  of  mental 
weakness,  approaching  if  not  reaching  the  degree  of  a  ter- 
minal   dementia.      Any    single    one    of   these   enumerated 


150  INSANITY. 

phases  may  be  absent.  In  a  large  number  of  cases  spas- 
modic conditions,  in  the  way  of  muscular  cruftipi,  chorea- 
like movements  of  the  facial  muscles,  epileptiform  and 
hysteroid  convulsions,  have  been  observed  to  accompany 
the  initial  period.  In  not  a  few  of  the  cases  the  initial 
depression  was  observed  to  be  accompanied  by  self-re- 
proaches relating  to  masturbatory  excesses,  and  very  fre- 
quently disappointment  in  love  determined  the  morbid 
ideas  of  the  patient;  and,  in  fact,  both  factors  are  exciting 
causes  in  many  cases  of  katatonia.  On  this  basis  the  ordi- 
nary melancholic  symptoms,  fear  of  poisoning,  delusions  of 
persecution,  and  dread  of  committing  unpardonable  crimes, 
crop  up  and  increase  the  resemblance  of  the  first  stage  to 
genuine  melancholia. 

The  excited  stage  presents  symptoms  of  a  kind  different 
from  those  of  ordinary  melancholia,  and  constitutes  a  con- 
necting link,  as  it  were,  between  the  symptoms  of  an  agi- 
tated melancholiac  and  those  of  a  lunatic  with  fixed  de- 
lusions. Some  of  the  patients  present  exaggerated,  others 
diminished,  self-esteem  ;  and  not  rarely  does  the  developing 
delirium  assume  an  expansive  tinge.  But  all  katatonics 
exhibit  a  peculiar  pathos,  either  in  the  direction  of  declam- 
atory gestures  and  theatrical  behavior,  or  of  an  ecstatic 
religious  exaltation.  Frequently  the  patients  wander 
about,  imitating  great  actors  or  preachers,  and  often  ex- 
press a  desire  and  take  steps  to  become  such  preachers  and 
actors.  In  America,  as  Kiernan  remarks,  the  chronic  stump- 
speaking  tendency  is  more  frequently  displayed  by  these 
patients,  and  in  a  negro  suffering  from  katatonia  the  con- 
versation in  excited  periods  was  noted  to  present  the 
grandiloquent  character  which  has  been  so  aptly  rendered 
in  the  minutes  of  the  "lime-kiln  club."  This  patient  had,, 
without  any  prodromal  symptoms,  fallen  down  suddenly 
while  at  work,  his  face  and  arms  twitching;  a  lucid  period 
followed,  the  patient  gradually  became  depressed,  and  in 
the  asylum  his  depression  gave  way  to  a  maniacal  condi- 
tion, which  was  followed  by  another  fit  of  depression, 
marked  by  numerous  hallucinations.  With  this  he  refused 
food  and  passed  into  a  cataleptoid  condition,  from  which 
he  suddenly  emerged  one  morning,  saying  that  he  was 
"equal  to  any  white  man."  Apparent  recovery  took  place, 
but  between  1871  and  1875  he  was  re-admitted  three  times. 
On  these  occasions  he  presented  mainly  alternations  be- 
tween atonic  stupor  with  catalepsy  and  a  peculiar  condition 


KATATONIC   INSANITY.  151 

which  was  so  characteristic  that  it  first  called  the  writer's 
attention  to  the  distinctness  of  the  disorder.  On  going  up  ta 
the  patient  and  loudly  addressing  him,  he  lifted  his  ordi- 
narily bowed  head  in  a  very  consequential  way  and  prefaced 
the  reply  to  any  question  by  Ae  words  "I  do  not  doubt 
but  what."     Asked  his   name,  for  example,  he  said,  "  I  do 

not  doubt  but  what  my  name  is  William   Henry  G ;" 

asked  his  age,  "  I  do  not  doubt  but  that  I  was  born  in  the 
year  1838,  so  my  mother  said;"  asked  his  nativity,  "I  do 
not  doubt  but  that  I  was  born  in  some  part  of  the  world;"' 
asked  whether  he  had  any  desire,  "I  do  not  doubc  but 
what  I  want  to  get  out  and  go  home  to  get  me  some  work,, 
in  order  that  I  may  buy  me  some  food,  a/;^some  clothes, 
and  — "  here  he  relapsed  into  the  passive  state.  Before 
he  answered  a  most  remarkable  series  of  grimaces  were 
gone  through,  a  series  of  spasms  of  the  oral  muscles,  which 
culminated  in  the  explosive  enunciation  of  the  first  word  of 
his  reply.  The  answers  were  deliberately  and  pompously 
given,  something  after  the  fashion  of  a  juvenile  actor.* 

In  a  better  educated  patient,  who  had  made  a  suicidal 
attempt  in  the  depressed  period,  in  obedience  to  hallucina- 
tory suggestions,  and  in  whom  an  exquisite  cataleptoid 
condition  developed,  the  excited  periods  were  marked  by 
a  tendency  to  contradict  everything  said  by  others.  On 
another  occasion  he  said,  "I  am  Arminius,  and  have  swal- 
lowed J.  E "    (his    name);    he  became  very  dignified, 

knocked  down  a  fellow-patient  for  sitting  on  the  same 
bench  with  him,  and  then  followed  another  cataleptic 
attack.  He  showed  rhythmical  movements  of  the  fingers, 
and  talked  incessantly  about  his  noble  descent,  appealing 
for  and  demanding  its  general  recognition.  The  grandiose 
ideas  were  mingled  with  self-accusatory  delirium,  and,  from 
intermingling  sounds  belonging  to  no  known  language 
with  his  mixed  German  and  English  flight  of  words,  he 
proceeded  to  talk  in  such  sounds  altogether,  making  the 
while  the  most  expressive  theatrical  gestures — risti  pili 
chinko  ti  ki  ti  king,  ter  pilli  mimili  nono  chichotitonifor 
tikohoforchink — marking  his  periods  well,  so  that  to  a 
casual  visitor  it  would  have  appeared  as  if  the  patient  were 
actually  speaking  in  some  Oriental  tongue. 

It  has  seemed  to  the  writer  as  if  there  were  at  times  a 
recognition  on  the  part  of  the  patients  that  their  "verbiger- 

*  The  italicized  words  were  peculiarly  emphasized. 


152  '  INSANITY. 

ation"  is  nonsensical,  and  that  they  have  a  silly  enjoyment 
of  the  "  fun."  Although  this  suspicion  can  be  based  only  on 
the  facial  expression  of  the  subjects  as  shown  when  they 
are  sharpl}^  cross-questioned,  it  seemed  convincingly  strong 
in  the  two  cases  referred  to. 

Kahlbaum  has  noted  the  tendency  of  katatoniacs  to  use 
diminutive  expressions,  a  tendency  which  can  be  better 
gratified  by  German  than  by  Anglo-American  patients,  and 
was  observed  in  the  case  just  cited.  One  of  Kahlbaum's 
patients  would  say,  for  example,  "  Ach  ich  bin  so  kleinc/ien, 
und  in  zwei  M'lnutc/ien  bin  ich  todtc/ien — Ich  bin  so  schwach- 
c/icn — jezt  bin  ich  bisweilen  so  gvosscAen — Ich  muss  sterb- 
c/ien,  alle  menschen  iodtc/ie/i,  ich  muss  wein<r//i!:'//,"  etc. 

The  hallucinations  of  this  form  of  insanity  are  commonly 
of  a  depressive  character.  Where  the  disorder  begins  in  a 
religious  ecstatic  state  the  devil  and  hell-fire  are  seen. 
One  patient  of  Kiernan's  saw  blood  on  everything  he 
looked  at,  another  was  followed  to  church  by  "droves  of 
dogs."  But  although  these  hallucinations  are  accompanied 
by  a  depression  like  that  of  melancholia,  there  is  rarely  the 
same  profound  painful  emotional  state;  and  the  expression 
of  the  patient  throughout  the  depressed  period,  and  even 
in  the  atonic  states,  often  indicates  rather  a  silly  hilarious 
tendency,  which  reaches  its  acme  in  the  excited  phases. 
The  acts  and  ideas  of  the  patient  in  these  latter  differ  from 
those  of  a  maniacal  subject  in  being  exceedingly  monoto- 
nous. Instead  of  being  constructive  and  productive  like  the 
maniac,  the  katatoniac  is  rather  destructive  and  oppositional 
in  his  tendencies:  he  contradicts  where  the  maniac  assents 
good-humoredly,  he  refuses  where  the  maniac  may  be  led  to 
consent.  It  is  in  harmony  with  this  that  refusal  of  food,  so 
rare  in  maniacal  delirium,  is  so  common  in  the  excited 
periods  of  katatonia,  and  that  it  is  as  difficult  to  get  a 
katatoniac  to  leave  his  bed  as  to  induce  the  maniac  to  re- 
tire to  his. 

Occipital  headache  of  an  occasionally  severe  character  is 
said  to  be  characteristic  of  katatonia  by  Kahlbaum. 

The  most  striking  phenomena  of  the  disorder  are  its 
cataleptic  periods.  The  catalepsy  is  typical  and  extreme. 
For  days,  weeks,  nay  months,  the  patients  are  immobile, 
resembling  sitting  corpses,  requiring  to  be  fed  by  the 
stomach-pump,  to  be  carried  to  and  from  their  beds,  and 
betraying  neither  by  look  nor  word  that  they  have  any 
mental  activity  left,  although  on  passing  out  of  this  state 


KAT ATONIC   INSANITY.  1 53 

they  often  recollect  something  of  that  which  has  occurred 
meanwhile.  On  raising  an  extremity  in  any  position  it 
will  retain  that  position.  The  writer  once  placed  the  pa- 
tient J.  E in  the  corridor,  with  one  foot  on  the  ground 

and  the  other  on  the  bench  behind  him,  his  head  extremely 
flexed,  one  arm  raised  out  horizontally  before,  and  the 
other  horizontally  behind  him,  and  watched  him  so  more 
than  half  an  hour  without  observing  any  material  change 
in  position.  On  making  the  rounds  of  several  wards  and 
returning  the  patient  was  still  found  in  the  same  position, 
his  arms  now  showing  a  tremor  and  gradually  sinking  to 
his  side.  In  another  case  the  patient  retained  any  posi- 
tion in  which  he  was  placed  for  a  day  at  a  time,  and  Kahl- 
baum  reports  one  of  even  longer  retention  of  a  constrained 
and  uncomfortable  position. 

The  prognosis  of  katatonia  is  relatively  favorable  as  re- 
gards life,  although  the  danger  of  pulmonary  tuberculosis 
developing  in  the  depressed  and  atonic  stages  of  the  trouble 
is  not  to  be  lost  sight  of.  As  to  recovery,  Kahlbaum  enter- 
tains very  sanguine  views,  which  the  writer's  experience 
does  not  sustain.  It  is  true  that  after  one  or  two  cycles  of 
the  symptomatic  series  related,  the  patients  can  be  dis- 
charged from  the  asylum  recovered,  and  that  this  occurs  in 
the  majority  of  instances;  but  relapses  are  exceedingly 
likely  to  occur.  The  progress  to  dementia  is  slow,  and 
rarely  does  the  latter  reach  an  extreme  degree.  Probably 
this  is  due  to  the  fact  that  it  is  in  these  very  cases  that  a 
pulmonary  affection  early  closes  the  patient's  career. 

It  is  not  yet  possible  to  make  any  positive  statements  as 
to  the  frequency  of  katatonia.  The  writer  found  two  per 
cent  of  over  two  thousand  male  lunatics  presenting  this 
form  of  insanity.  In  one  hundred  and  eighty-seven  tabu- 
lated cases  from  private  practice  but  one  instance  was  ob- 
served. 


154  INSANITY. 

CHAPTER   IV. 

Transitory  Frenzy. 

Transitory  frenzy  is  a  condition  of  itnpaired  consciousness, 
characterized  by  either  an  intense  matiiacal  fury  or  a  cojifused 
hallucinatory  deliriu?n,  whose  duration  does  not  exceed  the  period 
of  a  day  or  thereabouts. 

Numerous  instances  are  recorded  where  persons,  previ- 
ously of  sound  mental  health,  have  suddenly  broken  out  in 
a  blind  fury  or  confused  delirium,  which,  passing  away  in  a 
few  minutes  or  hours,  left  the  subject  deprived  of  a  clear, 
or  of  any,  recollection  of  the  morbid  period,  and  generally 
concluded  with  a  deep  sleep.  The  superficial  resemblance 
of  the  delirium  and  the  blind  and  destructive  fury  to  the 
delirium  and  fury  of  the  maniac  has  led  observers  to 
designate  this  condition  as  transitory  mania.  Others,  noting 
that  the  deliria  are  chiefly  of  an  anxious  character,  and 
that  the  violent  outbreak  often  bears  a  similar  relation  to 
the  deliria  that  the  melancholic  frenzy  bears  to  the  anx- 
ious delusions  and  hallucinations  of  melancholia,  have 
termed  it  transitory  melancholia.  Still  others,  guided  by  the 
fact  that  many  of  the  most  acute  epileptic  mental  disorders 
manifest  themselves  in  similar  explosions,  and  by  the  yet 
more  suggestive  fact  that  consciousness  is  entirely  or  nearly 
entirely  abolished  in  transitory  frenzy,  classed  it  among  the 
epileptic  disorders. 

But  it  would  have  to  be  considered  a  remarkable  form 
of  epilepsy  in  which  there  is  but  a  single  epileptic  attack 
(transitory  frenzy  usually  occurring  but  once  in  the  life  of 
an  individual),  and  that  attack  manifests  itself  in  the  guise 
of  a  transitory  frenzy  rather  than  in  a  convulsion,  and  in 
which  none  of  the  exciting  nor  the  predisposing  causes  nor 
any  of  the  somatic  signs  of  epilepsy  can  ever  be  deter- 
mined to  exist! 

The  theory  that  the  disorder  is  an  extremely  acute  mania 
in  some,  and  an  equally  acute  attack  of  melancholic  frenzy 
in  other  cases,  is  more  reasonable.  The  superficial  resem- 
blances on  which  this  theory  is  founded  have  been  briefly 
pointed  out.  They  are  strengthened  by  the  fact  that  a 
period  of  depression,  either  following  worr}',  vexation,  or 
somatic  disease,  is  sometimes  discovered  to  have  preceded 


TRANSITORY    FRENZY.  I  55 

the  outbreak.  But,  in  the  absence  of  more  positive  signs, 
and  in  view  of  the  specific  feature  of  amnesia  characterizing 
transitory  frenzy,  it  is  best  to  use  this  term,  as  committing 
us  to  no  doubtful  hypothesis,  and  best  expressing  the  lead- 
ing symptom  of  the  disorder. 

It  is  a  comparatively  rare  affection,  so  rare  that  many 
asylum  physicians  have  never  seen  a  case  of  it;  the  writer 
has  likewise  never  had  that  fortune.  But  its  existence  is 
too  well  authenticated  by  the  best  observers  to  be  called 
into  question  to-day;  and,  on  such  grounds  as  certain  writers 
have  advanced.  Utilitarian  considerations,  growing  out  of 
the  desirability  of  announcing  popular  views  on  the  witness- 
stand  as  a  step  to  further  patronage  by  the  legal  fraternity, 
have  had  their  day,  and  the  eloquent  language  of  Foville* 
the  elder,  translated  by  Kiernan,  may  be  cited  as  applicable 
to  the  rhodomontades  indulged  in  on  the  subject  of  transi- 
tory insanity.  "Here  is  a  fantastic  interpretation  which 
we  could  scarcely  have  expected,  and  which  is  hardly  cal- 
culated to  rank  as  a  scientific  ^xo^wQ.\\ovi..\  Other  than  this, 
it  is  not  to  scientific  procedures  that  the  author  has  re- 
course to  combat  the  existence  of  moral  insanity  and  mania 
transitoria;  it  is  only  by^  the  aid  of  appeals  thoroughly  per- 
meated with  religious  sentimentality,  and  drawn  from  the 
domain  of  literature,  that  the  author  declares  moral  insanity 
and  mania  transitoria  false,  absurd,  ridiculous,  and,  above 
all,  unworthy^  of  being  received  by  the  courts.  To  enable 
the  reader  to  judge  of  the  extra-scientific  method  adopted 
by  the  author,  we  give  the  conclusion  of  his  article:  '  Lastly, 
we  object  to  both  (mania  transitoria  and  moral  insanity) 
because  it  is  an  attempt  to  set  back  the  clock  of  the  century, 
and  to  revert  to  supernaturalism  and  superstition  in  medi- 
cine. It  is  an  attempt  to  curtain  the  windows  {sic')X  of  that 
science  whose  religious  duty  it  is  to  cast  light  and  not 
mysticism  around  disease — to  treat  it  not  as  a  personal 
devil  entirely,  to  be  exorcised  hy  philters  and  mummery,  but 
rather  as  the  perversion  of  a  natural  state  struggling  to 
regain  its  equilibrium.'  Many  physicians  will  be  astonished 
to  learn  that,  according  to  Dr.  Ordronaux,  they  are  deceived 
in  believing  themselves  in  the  pathway  of  modern  progress 

*  Annates  Me'dico-Psychologiqties,  1874. 

f  Alluding  to  his  statement  that  the  existence  of  moral  insanity  was 
due  to  Pinel's  benevolent  attempt  to  account  for  the  executions  of  the 
first  French  Revolution. 

X  Dr.  Foville's  interpolation. 


1 56  INSANITY. 

and  scientific  advance,  when  in  reality  they  are  returning 
to  the  dark  ages.  But  will  the  rhetoric  of  their  American 
colleague  induce  them  to  retrace  their  footsteps  ?" 

Transitory  frenzy  has  been  observed  to  follow  an  intense 
emotional  strain,  as  in  the  case  of  a  little  boy  reported  by 
Engelhorn,  who,  after  being  slightly  injured  by  a  gun- 
powder explosion  which  killed  his  brother,  was  thrown  into 
such  a  state  of  excitement  by  the  judicial  investigation  of 
the  occurrence  that  he  sank  back  in  bed,  then  suddenly  rose 
and  began  reciting  biblical  verses  and  mortuary  songs 
ecstatically,  unmindful  of  the  interruptions  of  his  sur- 
roundings. After  an  ensuing  sleep  the  patient  had  only 
the  confused  recollection  of  a  dream,  whose  contents  he  en- 
deavored to  recall  in  vain.  Kiernan — who  seems  to  strike 
at  the  root  of  the  matter  in  the  following  words,  written 
with  reference  to  Cook's  claim  that  transitory  mania  is  a 
cerebral  epilepsy,  "You  cannot  prove  the  epilepsy  ;  you  can 
the  mania,  and  it  is  transient  ;  and  is  it  not  as  easy  to  ac- 
cept the  theory  of  transitory  mania  as  it  is  to  go  wandering 
after  a  far-fetched,  forced  explanation  ?" — reports  the  case 
of  a  prisoner  who  made  a  sudden  violent  and  unprovoked 
attack  on  the  other  prisoners"  and  their  keepers  while  at 
supper.  Transferred  to  a  cell  he  became  violently  maniacal, 
continuing  thus  two  hours,  and  then  fell  into  a  slumber 
lasting  an  hour  and  a  half.  In  the  course  of  the  next  four- 
teen hours  he  was  transferred  to  an  asylum  and  was  found 
lucid,  though  slow  in  speech,  and  had  a  perfect  recollection 
of  everything  that  occurred  up  to  the  time  when  he  went  to 
get  some  salt  at  the  table.  The  next  thing  he  recollected 
was  the  finding  himself  in  a  cell.  Nothing  further  occurred. 
Another  patient,  whose  history  is  reported  by  the  same 
writer  (rendered  the  more  valuable  as  the  reporter  was  an 
eyewitness  of  the  attack  itself),  had  had  a  quarrel  with  her 
betrothed,  after  physical  exhaustion  following  night-watch- 
ing at  her  mother's  bedside.  On  going  to  another  appart- 
ment  after  the  quarrel  alluded  to,  she  found  that  two  live 
coals  had  fallen  on  a  dress  which  she  had  been  occupied  in 
sewing  for  two  days,  and  which  some  one  had  placed  near 
the  fire.  Hereupon  she  fell  into  what  was  apparently  a 
violent  rage,  tore  the  dress  to  pieces,  attempted  to  smash 
the  furniture,  and  continued  violently  excited  for  an  hour 
when  the  reporter  saw  her.  She  was  then  in  a  condition 
of  intense  frenzy;  said  the  doctor  was  so  dark  he  must  be 
the  devil,  and  made  two  assaults  on  him  and  continued  de- 


TRANSITORY    FRENZY.  I  57 

structive.  After  being  treated  with  restraint  and  the  cold 
pack  she  fell  into  a  deep  sleep,  on  awakening  from  which 
she  was  perfectl}^  rational,  and  recollected  nothing  that  had 
occurred  subsequently  to  the  discovery  of  the  fact  that  her 
dress  had  been  spoiled.  Kiernan's  summary  of  the  cases 
of  Calmeil,  Tardieu,  Le  Grand  du  Saulle,  Marc,  Hoffbauer, 
Krafft-Ebing,  Griesinger,  Pick,  Ray,  Rush,  and  numerous 
others,  is  substantially  as  follows  :  That  transitory  mania 
is  an  ordinary  form  of  acute  mania  characterized  by  the 
brevity  and  explosive  character  of  the  violence  ;  that  it  oc- 
curs in  persons  sane  prior  and  subsequently  to  the  attack, 
rarely  relapses  and  seldom  lasts  over  six  hours  ;  that  there 
are  no  very  apparent  prodromata,  and  no  sequelae  other 
than  the  slumber  and  turgidity  of  the  hands  ;  that  the  pre- 
disposing causes  are  heredity  and  an  excitable  tempera- 
ment ;  that  the  exciting  causes  may  be  alcoliolic  excesses, 
physical  exhaustion,  violent  emotion,  and  mental  strain,  and 
tliat  the  disorder  of  itself  tends  to  recovery. 

These  conclusions  seem  to  be  well  substantiated  by  the 
evidence  adduced,  though  it  is  clear  that  the  author  has 
formed  them  under  that  widely  prevalent  conception  of 
"  mania"  which  sees  in  destructive  or  violent  excitement 
the  essential  maniacal  characteristics.  If  the  word  "  furor" 
or  better  still  "frenzy"  were  substituted  no  exceptions 
could  be  taken  to  them. 

It  is  a  significant  fact,  that  while  epilepsy  is  not  found  in  / 
the  ancestry  or  collateral   relations  of  such"  prnients^  acute  I 
mental  disorders  of  a  furious  or  maniacal   type   are   occa- 
sionalh^  noted  to  have  occurred.     A   tendency  to   so-called 
head-congestion  has  been  noted   in   the   family   history  of 
others,  as  in  Kiernan's  second  case. 

Insolation,  prolonged  insomnia,  exposure  to  extreme  cold, 
and  violent  emotional  and  intellectual  strain,  have  been 
frequently  determined  to  have  been  the  exciting  causes.  A 
classical  instance  is  one  related  by  Reich:*  Four  boys  be- 
tween the  ages  of  six  and  ten,  who  had  been  out  sleighrid- 
ing  on  an  extremely  cold  day,  on  returning  home  were  sud- 
denly ushered  into  a  room  which  was  overheated  ;  a 
transitory  insanit)' followed,  marked  by  a  maniacal  delirium, 
excitement,  and  hallucinations,  which  rapidly  subsided  giv- 
ing way  to  a  critical  sleep.  On  the  whole  it  seems  that 
those  factors  which  lead  to  disturbances  in  the  cerebral  cir- 

*  Berliner  Klinisc/ie  IVoc/iense/irift  liZi.    No.  8. 


158  INSANITY. 

culation,  of  a  probably  congestive  character,  are  the  ones 
active  in  the  production  of  transitory  frenzy.  In  not  a  few 
of  the  recorded  cases  the  fury  of  the  patient  and  his  am- 
nesia for  the  furious  period  remind  one  of  the  rage  of  the 
bull  or  the  male  elephant,  conditions  which  are  looked 
upon  as  transitory  nervous  disturbances  in  those  animals, 
and  which,  like  the  transitory  frenzy  of  man,  are  as  a  rule 
isolated  explosions  in  the  individual's  career. 


Sub-order   B. 

Forms  not  Characterized  by  a  Fundamental  Emotional  Dis- 
turbance. 

Stuporous  Insanity. 

Primary  Confusional  Insanity. 

Primary  Mental  Deterioration. 

The  Secondary  and  Terminal  Deteriorations. 


CHAPTER   V. 

Stuporous   Insanity. 


Stuporous  insanity  consists  in  the  simple  impairment  or 
suspension  of  the  ?nental  energies,  unmarked  by  any  ejnotional  or 
other  perversion. 

In  some  young  persons,  such  who  have  as  a  rule  not 
passed  the  twenty-fifth  year,  and  in  whom  there  is  either  a 
congenital  or  an  acquired  weakness  of  the  nervous  sys- 
tem, there  develops  a  condition  of  apathy  which  may  reach 
a  degree  as  intense  as  tlie  atony  which  characterizes  melan- 
cholia attonita.  But  there  is  a  profound  difference  between 
the  two  conditions:  While  the  atony  in  melancholia  at- 
tonita is  the  result  of  an  overwhelming  delusion  based  on  a 
painful  emotional  state,  it  is  in  stuporous  insanity  a  phenom- 
enon by  itself,  the  direct  result  of  a  physical  condition, 
and  not  translated  through  an  intermediate  emotional  per- 
version. 


STUPOROUS   INSANITY.  1 59 

Stupor  may  be  best  compared  to  the  condition  of  indif- 
ference and  indolence  which  sometimes  follows  excesses, 
or  results  from  prolonged  night-watches,  and  indeed  it  has 
a  similar  causation.  It  develops  in  one  of  two  ways: 
Either  the  patient,  in  consequence  of  masturbation,  starva- 
tion, or  exhausting  discharges,  develops  a  gradually  deepen- 
ing apathy  and  anenergy;  or,  after  a  profuse  haemorrhage 
or  a  powerful  shock  to  the  nervous  system,  the  stupor  is 
brought  to  its  climax  in  an  instant. 

At  the  height  of  this  disorder  the  patient  is  in  a  state  of 
immobility,  he  does  nothing  of  his  own  initiative.  Sensi- 
bility is  impaired  as  much  as  the  mobility,  so  that  even 
powerful  punching,  nay,  the  cautery,  may  not  be  perceived 
by  the  patient.  The  reflex  acts  are  sometimes  impeded  to 
such  an  extent  that  the  food  which  is  placed  in  the  mouth 
of  the  patient  will  not  excite  the  act  of  swallowing,  unless 
it  be  pushed  well  backwards  into  the  pharynx.  There  is 
also  a  corresponding  anenergy  of  the  involuntary  muscles: 
the  pupils  are  dilated  and  react  poorly,  the  heart's  action 
is  greatly  enfeebled,  the  pulse  tardy,  small,  and  fre- 
quent, the  temperature  is  slightly  lowered,  and  the  extremi- 
ties are  cold,  while  oedema  of  the  feet  is  constantly,  and 
that  of  the  hands  and  face  sometimes  observed. 

The  mental  activity  shares  in  the  depression  and  aboli- 
tion of  the  other  nervous  and  general  somatic  functions. 
The  stuporous  lunatic's  recollection  of  the  period  of  his  / 
illness  is  found  to  be  entirely  desrroved  on' pxflminafio7r~V 
after  convalescence,  'the  mind  throughout  the  disorder  /~ 
appears  to  be  a  blank, 'and  the  only  indication  that  a  feeble 
appreciation  of  the  outer  world  still  exists  is  to  be  found  in 
the  occurrence  of  tremulous  movements  of  the  muscles 
when  the  patient  is  by  signs  imperatively  ordered  to  do  any 
given  thing,  and  in  an  acceleration  of  the  pulse  when  loud 
noises  are  made  in  his  immediate  neighborhood.  Other- 
wise the  stuporous  lunatic  manifests  no  reaction,  even  to 
the  vegetative  needs,  and  his  faeces  and  urine  are  passed 
without  any  knowledge  on  his  part,  or  any  change  in  his 
position,  while  the  saliva  dribbles  from  his  mouth.  The 
urine  is  rich  in  phosphates,  and  the  physiological  dis- 
charges of  the  skin  and  uterus  are  suppressed  as  in  other 
atonic  states. 

At  times  there  are  observed  changes  lasting  for  a  brief 
period,  during  which  the  patient  manifests  a  slight  return 
of  mobility,  or  even  speaks  a  few  words,  either  relating  to 


l6o  INSANITY. 

the  subjects  which  occupied  his  mind  last,  or  consisting 
merely  in  parrot-like  repetitions  of  what  is  said  and  done 
around  him.  If  recovery  is  to  occur,  these  periods  become 
more  frequent,  of  longer  duration,  and  their  lucidity  ap- 
pears more  marked. 

Stuporous  insanity  may  run  its  course  in  a  few  weeks, 
but  its  usual  duration  is  from  one  to  three  months.  The 
prognosis  is  highly  favorable,  probably  ninety  per  cent  of 
"the  patients  recovering.  Recovery  is  most  rapid  in  very 
young  subjects,  and  in  those  in  whom  the  stupor  has  been 
produced  suddenly,  as  after  a  fright  or  a  profuse  haemor- 
rhage. It  is  least  rapid  and  least  likely  to  occur  in  cases 
arising  after  masturbation.  When  recovery  does  not  occur 
the  apathetic  variety  of  terminal  dementia  or  pulmonary 
disease  closes  the  history. 

This  disorder  is  known  in  American  and  English  asylums* 
as  acute  or  primary  dementia.  The  writer  considers  the 
term  "dementia"  a  very  unfortunate  one;  for  alienists  are 
accustomed  to  associate  with  this  term  the  idea  of  incura- 
bility, or  at  least  of  a  deterioration  following  some  other 
psychosis.  Again,  by  employing  the  adjective  "acute,"  they 
impress  the  novice  with  the  idea  that  a  set  of  symptoms 
like  those  of  chronic  dementia  may  present  themselves  in 
an  acute  form — which  is  not  the  case — or  on  an  analogous 
basis — which  it  would  be  fallacious  to  maintain!  Add  to 
this  the  fact  that  there  is  such  a  thing  as  a  "  primary  demen- 
tia," a  dementia  like  terminal  dementia,  but  arising  inde- 
pendently and  developing  progressively,!  which  is  as  differ- 
ent from  stuporous  insanity  as  one  thing  can  well  be 
from  another,  and  the  further  fact  that  both  "acute"  and 
•'  primary  dementia"  have  been  used  as  designations  for 
hebephrenia  and  masturbatory  insanity,  and  it  will  appear 
reasonable  to  recommend  the  dropping  of  both  terms  in 
this  relation. 

The  important  differential  diagnostic  relations  of  stupor- 
ous insanity  will  be  found  detailed  in  the  last  part  of  the 
work(/^  3?  0  W2), 

*  And  by  a  few  German  authorities  as  "  primary  curable  dementia." 
\  Described  by  Voisin  as  insanity  from  atheromatous  degeneration  of 
the  brain-vessels,  and  in  this  treatise  as  Primary  Mental  Deterioration. 


PRIMARY    CONFUSIONAL   INSANITY.  l6l 

CHAPTER  VI. 

Primary  Confusional  Insanity. 

Primary  confusional  insanity  is  a  form  of  mental  derange- 
ment characterised  by  incoherence  and  confusion  of  ideas  with- 
out an  essential  emotional  disturbance  or  true  dementia. 

Just  as  stuporous  insanity  imitates  one  of  the  most  fre- 
quent phenomena  of  melancholia,  yet  differs  from  it  in  the 
absence  of  the  fundamental  painful  emotional  state  charac- 
terizing the  latter,  so  there  is  an  acute  insanity  marked  by  a 
prevalent  confusion  in  the  conceptional  sphere  resembling 
maniacal  delirium,  without  having  the  same  pleasurable 
emotional  basis  as  the  latter. 

Just  as  the  resemblance  between  the  atony  of  melancho- 
lia and  that  of  stuporous  insanity  is  superficial,  so  there  is 
only  a  surface  similarity  between  the  confusion  of  mania 
and  that  of  acute  confusional  insanit}'.  The  confusion  of 
mania  is  not  the  expression  of  a  genuine  confusion  of  ideas, 
but  of  a  disparity  between  the  number  of  ideational  items 
and  the  word-channels  through  which  these  seek  exit;  that 
of  confusional  insanity  is  an  expression  of  a  true,  es- 
sential incoherence  in  ideation.  Whether  the  patient 
speak  slowly  or  deliberately,  incoherence  is  equally  noticea- 
ble.    This  is  not  the  case  in  mania. 

^Xhjs  disorder  is  rare  and  develops  rapidly  on  a  basis  of 
cerebral  exhaustion.  .^  Consciousness  is  blurred  in  parallel- 
is  nr\\athT]ie~conceptional  disturbance,  and  the  patients  on 
recovering  have  as  a  rule  but  a  very  crude  recollection  of 
their  condition.  Its  dara^joa  is  variable,  comprising  weglcs 
or  months,  and  theprognosis  is  as  good  as  that  of  stuporous 
insanit}',  with  which  conditiorrit  also  has  a  resemblance  as 
to  etiology;  emotional  shock,  cerebral  overstrain,  exhaust- 
ing diseases,  and  excesses  being  the  principal  factors  re- 
sponsible for  confusional  insanity. 

The  patients  suffering  from  this  psychosis,  after  a  rapid 
rise  of  their  symptoms  during  a  period  of  incubation 
rarely  exceeding  a  few  days,  present  hallucinations  and 
delusions  of  a  varied  and  contradictor)'^  character.  The 
delusions  resemble  those  of  mania  and  more  often  those  of 
melancholia,  but  no  emotionaL.state  is  as s pc] at e d_  with 
them.     The  patients  assert  in  the   same   breath  that  their 


1 62  INSANITY. 

property  is  being  stolen  and  that  they  are  going  to  take 
part  in  some  great  state  affair.  A  patient  of  Fritsch's, 
after  protesting  that  she  was  innocent  of  the  disease  of  a 
child  which  she  had  been  nursing  through  an  illness,  said 
that  a  gold  wagon  was  going  to  be  sent  for  her;  in  the 
asylum  the  same  patient,  after  rambling  incoherently  about 
the  medicines  the  said  child  received  and  the  accusations 
made  against  her,  resisted  all  attempts  to  transfer  her  to 
the  ward,  saying  that  she  "had  to  fight  for  her  country,  be- 
cause she  was  to  be  a  man."J^_,^ 

The  speech  in  confusional  insanity  is  characteristic;  al- 
though there  is  no  richness  in  ideation  as  with  mania  the 
sentences  are  left  uncompleted,  and  are  entirely  irrevelant 
as  well  as  incoherent.  A  patient  of  this  kind  told  the  _ 
writerthe  following:  "  I  am,  I — ,  I  don't  know  that — I — is 
dead — -funerals  are — how  do  you  do — met  you  in  Boston 
steamer — this  is  London — London — I  am  sure  of  it — see! 
I  have  not  forgotten  everything — there  are  not  so  many 
now — "  Here  he  was  interrupted  by  the  question  what 
he  referred  to;  he  replied:  "The  police  of  London  have 
their  wires  to  watch — you  know,  to  watch — all  the  furni- 
ture— look  at  that  horse — it  is  alive — it  is  not  a  wooden 
horse — [it  was] — it  looks  so — I  think  it  is — my  poor  father — 
who  was  the  eldest  son  of  my  niece — that  is  a  mechanism 
working  on  the  principle — the  wires  work  up  and  down — 
move  it  off  the  wall — see  them — that  furniture  is  all  alive 
— I  know  my  head  is  wrong — I  can  write  as  good — my 
wife  and  my  nieces  arrested  and  confined  forever — spirits 
and  the  headache  is  intolerable — meat  is  not  for  the  right- 
eous— I  am  an  orthodox  man — the  poison  causes  these  fan- 
cies— I  never  had  haemorrhoids — I  never  had  consumption— 
— but  how  nice  to  meet  you  here  in  the  Boston  steamer. "^^    /_ 

Delusions  of  identity  are  very  common.  The  patients 
believe  they  are  not  in  the  same  place,  or  they  recognize  as 
old  acquaintances  persons  to  whom  these  bear  no  resem- 
blance. It  is  noteworthy  that  a  large  number  of  the  pa- 
tients are  aware  that  a  change  has  taken  place,  that  they 
are  no  longer  their  former  selves,  and  they  may  be  able  to 
give — by  snatches,  it  is  true — a  tolerably  fair  account  of 
the  circumstances  preceding  the  outbreak  of  the  disease. 
But,  as  the  latter  develops,  the  patients  cease  to  recognize 
their  position,  or  to  complain  of  the  "  head  trouble"  whose 

*  Translated  from  the  German. 

7,  ;t^  i^  ^/'■><^-7^/^  >t^t^*^<-^ 


PRIMARY   MENTAL  DETERIORATION.  163 

existence  they  previously  admitted, and  at  most  they  speak 
of  their  former  selves  in  the  third  person,  or  manifest  a 
confused  variety  of  double  consciousness.!  vvnen  the  hal- 
lucinations, as  is  frequently  the  case,  preponderate  from  the 
beginning,  the  disorder  w^e  have  here  considered  is  termed 
by  some  acute  hallucinatory  confusion.  From  the  superficial 
resemblance  of  the  verbigeration  of  patients  exhibiting  this 
form  of  insanity  to  monomaniacs  with  episodial  delirium, 
Westphal  was  induced  to  classify  it  among  the  monomanias 
(Primare  Verriicktheit)  a  most  improper  arrangement.  It 
'would  be" as  just  to  comprise  almost  every  other  form  of 
insanity  under  monomania  on  the  same  basis.  I  In  confu- 
sional  insanit}^  there  is  no  method  as  in  monomania,  no 
productiveness  as  in  mania,  no  origin  of  the  delusions  from 
a  process  of  reasoning  and  reflection  as  in  the  former,  nor 
a  flight  of  ideas  as  in  the  latter. 

Recovery  is  gradual,  the  patient  becoming  progressively 
clearer;  his  somatic  complaints,  such  as  headache,  then 
occupy  his  attention  more  than  his  incoherently  recounted 
delusive  troubles,  and  finally  reason  is  entirely  restored. 
In  only  a  small  proportion  of  cases  does  the  insanity  re- 
main and  the  patient  become  permanently  deteriorated, 
his  disorder  then  appearing  as  a  form  of  Mr^;z/V  confusional 
insanity. 


CHAPTER   VII. 

Primary  Mental  Deterioration. 

Primary  7ne7ital  deterioration  is  an  uncomplicated  enfeeblement 
of  the  mind  occurring  independently  of  the  developmental  and  in- 
volutional periods. 

In  most  persons  surviving  the  sixtieth  year  a  pronounced 
and  general  failure  of  the  mental  powers  occurs  at  or  after 
that  period.  This  is  the  ordinary  senile  change,  and  can- 
not be  considered  to  be  in  all  cases  a  pathological  one. 
But  where  a  similar  deterioration  anticipates  the  senile 
period  it  can  only  be  accounted  for  on  a  pathological  basis. 
Such  a  decay  of  the  mind  is  observed  in  paretic,  syphilitic, 
and  organic  dementia,  and  is  also  found  to  be  a  sequel  of  nu- 
merous other  forms  of  insanity.  In  all  these  instances  the 
mental  failure  is  accompanied  by  active  symptoms  which  in 


164  INSANITY. 

their  association  with  the  dementia  characterize  the  given 
variety  of  mental  disorder.  It  is  not  so,  however,  with  a  cer- 
tain class  of  cases  in  which  progressive  deterioration, 
chiefly  limited  to  the  higher  mental  faculties,  is  the  only 
notable  indication  of  a  cerebral  disturbance. 

Crichton  Browne  described  as  "  chronic  brain-wasting" 
a  disorder  in  which  there  is  confusion  and  failure  of  the 
memory,  lack  of  attention,  and  general  inertia.  With  this 
the  muscular  power  is  enfeebled,  the  articulation  is  af- 
fected, the  pupils  are  unequal,  and  the  temperature  is  sub- 
normal, while  the  patient  generally  complains  of  a  sensa- 
tion of  pressure  or  fulness  in  the  head.  Convulsive 
attacks  occurring  on  one  or  both  sides  heighten  the  re- 
semblance to  paretic  dementia,  and  the  progress  of  the 
disease,  with  rare  exceptions  in  which  recovery  occurs,  is 
toward  complete  extinction  of  the  mental  faculties. 

The  writer  has  observed  a  similar  condition  among  busi- 
ness men,  particularh'  among  those  whose  duties  were  of  a 
varied,  exciting,  and  exhausting  character,  who,  with  an 
expensive  domestic  establishment  on  the  one  hand  and  a 
tottering  firm  on  the  other,  resorted  to  Wall  Street  to  make 
good  the  difference.  It  is  also  not  uncommon  with  mem- 
bers of  the  legal  and  other  professions,  to  the  practice  of 
which  excitement  and  strain  are  incidental.  In  short,  the 
etiology  of  this  affection  is  very  similar  to  that  of  paretic 
dementia,  and  it  may  not  be  improper  to  consider  it  an, 
as  it  were,  functional  analogue  of  that  organic  malady. 
The  paralytic  and  convulsive  symptoms  noted  by  Crichton 
Browne  have  not  been  observed  in  the  writer's  cases,  and, 
judging  by  the  serious  prognosis  given  by  that  author,  it  is 
probable  that  he  has  considered  genuine  cases  of  paretic, 
syphilitic,  and  "organic"  dementia  in  conjunction  with 
those  cases  to  which  the  writer  would  limit  the  designa- 
tion "primary  mental  deterioration." 

The  first  signs  noticed  are  generall)^  recognized  by  the 
patient  himself.  He  experiences  a  lack  of  energy  both 
mental  and  physical.  The  warning  being  disregarded, 
and  the  strain  kept  up,  the  abused  nervous  system  replies 
with  insomnia.  The  patient  finds  it  difficult  to  go  to  sleep, 
and  when  he  finally  drops  off  into  a  brief  and  fitful  slum- 
ber it  fails  to  refresh  him,  and  the  irritable  condition  of 
his  brain  manifests  itself  in  dreams,  whose  subjects  are  gen- 
erally taken  from  his  daily  occupations  and  cares.  The 
patient  now  becomes  dyspeptic,  and  signs  of  functional  or 


PRIMARY   MENTAL   DETERIORATION.  165 

organic  heart  disorder,  or  of  the  prodromal  period  of 
Bright's  disease  may  be  noted  by  the  examining  physi- 
cian. Often  tlie  patient  becomes  prematurely  gray.  There 
can  be  little  doubt  that  continuous  mental  worry  and 
emotional  strain  are  competent  to  provoke  all  these  dis- 
orders, particularly  in  predisposed  individuals.  At  this 
stage  the  warning  may  be  heeded,  and  a  comparatively 
healthful  mental  state  resumed  under  treatment;  but  if  the 
exciting  causey  §5^..^£Pl  ^^  operation  actual  dementia  may 
be  the  result/^At  nrsi  l^e  subject  is  noted  to  be  absent- 
minded:  thelaWyer  finds  that  he  is  unable  to  fix  his  atten- 
tion on  his  opponent's  argumentation;  the  physician  dis- 
covers that  he  is  at  a  sudden  loss  in  writing  prescriptions 
and  forgets  to  add  important  directions,  not  in  single  in- 
stances, but  repeatedly;  the  stenographer  finds  that  his 
hand  fails  him;  and  the  literary  man  omits  words,  or  mis- 
spells where  he  was  previously  methodical  and  accurate. 
Important  engagements  are  broken,  articles  of  value  mis- 
laid, addresses  forgotten,  expenditures  unrecorded,  and, 
with  the  mtensification  of  all  these  symptoms,  complete 
fatuity  may  be  developed.  Yet  it  is  noteworthy  that,  while 
the  memory  fails,  attention  becomes  difficult,  and  the 
power  of  acquiring  new  impressions  is  impaired,  the 
patient  may  in  fits  and  starts  show  his  old  brilliancy  in 
reasoning.  Let  him,  however,  attempt  to  keep  up  the  ef- 
fort any  considerable  length  of  time  and  he  will  break 
down.  ^  ^ 

C^-    On  the  basis  of  the  condition  just  described  any  of  the  \^ 

primary  simple  psychoses  may  develop,  and  it  may  prove 
to  be  the  preliminary  phase  of  a  paretic  dementia.  But  it 
may  also  continue  to  exist  by  itself,  and  terminate  in  a  rel- 
ative recovery  or  in  death  v^^ithout  further  complication. 
'As  a  rule  complete  rest  and  proper  tonic  and  moral  treat- 
ment are  capable  of  checking  the  disorder  at  any  but  its 
later  periods,  and  while  a  complete  restitutio  ad  integrum  has 
never  been  observed  by  the  writer,  and  even  the  most  fa- 
vorable cases  reveal  some  permanent  damage,  however 
slight  and  however  unnoticeable,  to  those  who  have  not 
known  the  individual  before  his  illness,  some  of  the  pa- 
tients remain  free  from  a  renewed  attack,  and  may  even 
return  to  business  of  a  less  exciting  character,  and  success- 
fully fill  a  responsible  position  in  life. 

This  disorder  rarely  comes  under  the  notice  of  the  asylum 
physician.    The  absence  of  delusions,  of  morbid  propensities, 


1 66  INSANITY. 

and  of  excitement  account  for  this  fact.  Occasional!}-  a 
suicidal  tendency  may  render  sequestration  necessary,  and 
the  mistake  is  apt  to  be  made  of  confounding  such  a  case 
with  paretic  dementia  of  a  melancholic  or  hypochondriacal 
invasion-type.  Add  to  this  the  fact  that  a  laxity  of  the 
facial  and  a  weakness  of  other  muscles,  as  well  as  forget- 
fulness  of  words  and  facts,  are  common  accompaniments,, 
and  the  possibility  and  probability  of  this  error  being  com- 
mitted will  be  understood.  The  future  history  of  the  case 
exposes  its  true  nature,  and  a  careful  analysis  will  show 
that  the  suicidal  attempt  was  not  the  outcome  of  emotional 
depression,  delusion,  or  hallucination,  but  the  result  of  a 
process  of  reasoning,  often  correctly  based  on  correct  prem- 
ises, by  a  patient  fully  appreciating  his  sad  position.  The 
misery  of  the  sufferer  is  often  aggravated  by  his  recog- 
nition of  the  fact  that  his  affection  for  his  dearest  friends 
and  relatives,  like  his  more  strictly  intellectual  faculty,  has 
become  blunted,  and  that  he  is  unable  to  recall  these  feel- 
ings in  that  intensity  which  characterized  them  in  his 
healthy  state. 


CHAPTER   VIII. 
The  Secondary  and  Terminal  Deteriorations, 

In  the  foregoingchapters  on  mania,  melancholia,  stupor- 
ous and  other  primary  forms  of  insanity,  reference  has  been 
repeatedly  made  to  the  fact,  that  in  a  certain  series  of 
cases,  while  death  does  not  ensue,  recovery  is  not  effected; 
and  a  secondary  and  chronic  psychosis  develops  from  the 
primary  disorder. 

A  thorough  consideration  of  dementia  is  nearly  tanta- 
mount to  a  study  of  all  that  which  the  older  authorities 
designated  as  "  secondary  forms."  As  the  term  is  generally 
used,  however,  it  refers  to  te?fninal  dementia, v^hich  is  the  or- 
dinary conclusion  of  most  chronic,  and  the  uncured  acute 
insanities.  Inasmuch  as  terminal  dementia  develops  from 
primary  forms  differing  greatly  among  themselves,  and  the 
transition  from  the  primary  insanity  to  dementia  is  gradual 
and  progressive,  it  will  be  perceived  that  numerous  grades 
and  varieties  of  this  affection  must  exist.     It  is  customary 


SECONDARY   AND   TERMINAL   DETERIORATIONS.    1 6/ 

in  order  to  fully  characterize  their  varieties,  to  state  what 
primary  form  preceded  the  dementia.  Thus  we  say:  de- 
mentia follows  mania,  melancholia,  or  stuporous  insanity^ 
Sometimes  we  are  enabled  to  determine  from  the  demented 
patient's  symptoms  what  the  primary  form  of  his  insanity 
was;  in  one  case  we  may  find  residua  of  the  delusions  of 
marital  infidelity  with  physical  symptoms  indicating  the 
previous  existence  of  alcoholic  mania,  in  another  the  delu- 
sions of  persecution,  and  incoherent  ideas  growing  out  of 
such,  which  point  to  the  previous  existence  of  melancholia. 

Dementia  must  not  be  confounded  with  imbecility;  while 
both  dementia  and  imbecility  imply  a  profound  general  de- 
fect in  the  mental  sphere,  the  former  term  should  be  always 
limited  to  acquired  enfeeblejnent,  the  latter  to  the  original 
feeblemindedness  due  to  foetal  or  infantile  arrest  of  develop- 
ment. Much  confusion  has  also  arisen  from  the  unfortunate 
use  of  the  terms  "acute"  and  "primary  dementia."  Acute 
dementia  is  applied  to  a  primary  insanity  more  properly 
designated  as  acute  stupor,  while  "  primary  dementia"  is  in- 
differently applied  to  stupor,  insanity  of  pubescence,  and 
primary  deterioration.  The  designation  dementia  should 
be  limited  to  permanent  mental  deteriorations,  and  a  dis- 
crimination should  be  made  between  the  dementia  from 
gross  organic  disease  of  the  brain,  the  paretic  dementia  to 
be  considered  in  a  later  chapter,  and  that  senile  dementia 
which  is  a  natural  manifestation  of  brain-involution  on  the 
one  hand,  and  the  trouble  we  are  here  considering,  which 
implies  the  previous  existence  of  some  well-marked  primary 
form  or  the  other. 

The  course  of  the  development  of  this  secondary  insanity 
is  twofold:  either  the  primary  disorder  passes  directly  into 
dementia,  or  it  does  so  indirectly,  through  an  intermediate 
stage  of  chronic  secondary  mania,  with  confusion  of  ideas 
and  mental  enfeeblement  as  prominent  features.  When 
dementia  follows  the  latter  affection  it  is  "  tertiary."  But, 
as  it  does  not  in  this  case  materially  differ  from  the  demen- 
tia which  is  a  more  direct  sequence  of  and  secondary  to 
the  primary  forms  of  mental  disturbance,  it  is  best  to  de- 
vise some  common  term  for  both.  The  framing  of  such  a 
term  may  be  based  on  the  fact  that,  whether  secondary  or 
tertiary,  these  varieties  of  dementia,  in  contradistinction  to 
the  primary  dementia  from  coarse  brain  disease  and  senes- 
cence, are  the  tertnifial  epochs  in  the  history  of  prior  psycho- 
sis.    They  may  hence  be  termed  terminal  dementias. 


1 68  INSANITY. 

In  its  widest  sense  this  designation  might  apply  also  to 
the  dementia  which  closes  the  history  of  epilepsy,  as  well  as 
of  epileptic  and  alcoholic  insanity.  But,  as  the  dementia 
in  these  cases  is  customarily  designated  as  epileptic,  alco- 
holic, etc.,  according  to  its  etiology,  and  these  adjectives  in- 
dicate also  the  clinical  characters  of  dementias  which  are 
different  from  those  of  the  dementia  following  the  ordinary 
forms  of  insanity,  the  group  of  terminal  dementia  may  be 
advantageously  limited  to  the  latter. 

For  stuporous  insanity  and  melancholia  attonita  it  re- 
quires nothing  further  than  for  the  patient  to  remain  in  the 
atonic  and  stupid  condition  a  longer  period  than  in  favor- 
able cases  to  constitute  a  terminal  dementia.  Occasionally 
the  exhaustion  following  violent  outbreaks  of  maniacal 
furor  passes  into  dementia  as  directly.  In  all  these  cases 
the  mental  deterioration  is  of  a  passive  variety,  one  whose 
characters  are  simply  negative;  the  mental  processes  gen- 
erally are  nullified,  the  countenance  is  devoid  of  expression, 
the  extensors  are  not  innervated,  the  flexors  consequently 
predominate,  and  the  patients  in  their  inactivity  resemble 
cowering  statues  or  animals  whose  cerebral  hemispheres 
have  been  partly  removed.  What  was  a  merely  functional 
and  temporary  clouding  of  the  mental  sphere  in  atonic 
melancholiacs  and  the  stuporous  insane  now  becomes  an 
organic,  progressive,  and  permanent  condition,  which  finds 
an  anatomical  expression  in  the  accompanying  cerebral 
atrophy. 

These  unhappy  creatures  constitute  a  considerable  pro- 
portion of  the  pauper  asylum  *  or  poorhouse  population, 
and  they  largely  people  the  "  unclean"  w'ards  of  all  asylums. 
Here  they  may  be  seen  on  the  benches,  mute,  expression- 
less, devoid  of  any  spontaneity,  requiring  to  be  fed,  con- 
ducted to  the  water-closet,  dressed  and  brought  to  bed  like 
children.  As  deterioration  proceeds  even  the  few  words  re- 
tained in  their  limited  vocabulary  become  lost,  and  complete 
mental  annihilation  precedes  physical  death,  which  occurs 
either  through  the  extension  of  central  paralysis  to  the 
centres  of  vegetative  life,  or  by  inter-current  diarrhoeas  and 
pulmonary  affections.  As  a  rule  these  patients  do  not  live 
more  than  a  few  years. 

Other  demented  patients  appear  docile,  willing  to  assist 

*  Of  the  2,297  pauper  lunatics,  referred  to  elsewhere  as  tabulated  ac- 
cording to  their  form  of  insanity  by  the  author,  334,  or  over  fourteen  per 
cent,  were  terminal  dements. 


SECONDARY   AND   TERMINAL   DETERIORATIONS.    169 

the  attendants  in  the  performance  of  routine  duties,  are  em- 
ployed in  copying  records,  in  nursing  debilitated  comrades, 
and  attending  to  the  cattle  on  the  farm,  while  the  great  ma- 
jority are  lounging  listlessly  around  the  corridor,  or  stand 
or  sit  in  one  place  all  day,  indulging  in  some  rythmical 
movements,  or  vociferating  the  same  set  phrases.  Some 
dements  pass  their  evacuations  without  any  regard  to  time 
and  place,  and  even  delight  in  doing  so  in  the  most  unusual 
localities,  and  in  the  most  unseemly  manner;  others  do  so 
because  they  are  simply  oblivious  to  the  calls  of  nature. 
Certain  of  these  patients  require  to  be  fed  by  force,  others 
will  eat  as  soon  as  the  automatic  processes  are  started  by 
seating  them  at  table,  and  putting  eating  utensils  in  their 
hands,  still  others  are  ravenous  eaters,  and  their  ideations 
revolve  within  the  limits  of  the  daily  bill  of  fare,  whose 
items  perhaps  they  will  recite  or  chant  all  day.  The  funda- 
mental feature  of  terminal  dementia  is  an  acquired  mental 
defect,  and  this  may  vary  from  a  mere  loss  of  memory, 
usually  of  recent  events,  or  of  the  reasoning  power,  to  the 
nearly  complete  extinction  of  mind.  The  loss  of  memory 
may  be  of  every  grade;  in  some  it  involves  a  special  period 
of  life;  in  others  the  period  of  the  primary  disease;  in  all 
more  or  less  the  memory  of  recent  events.  Old  recollec- 
tions may  exist  with  normal  intensity,  but  there  is  a  failure 
of  the  receptive  sphere  to  register  new  impressions,  or  at 
least  to  register  them  perfectly;  indeed  it  is  to  be  presumed 
that  it  is  the  struggle  between  the  old  healthily-established 
mental  combinations,  and  the  imperfect  and  hampered 
products  of  the  newer  ones,  which  accounts  for  the  phenom- 
enon of  double  consciousness,  and  other  disturbances  of  the 
sense  of  personal  identity  sometimes  found  in  the  early 
phase  of  terminal,  as  in  other  varieties  of  dementia. 

There  is  another  form  of  terminal  dementia  in  which 
apathy  is  not  so  pronounced,  and  inactivity  cannot  be  said 
to  exist.  On  the  contrary,  the  patients  are  restless,  talkative, 
and  even  obtrusive  or  destructive.  But  their  violence  is  with- 
out purpose,  and  even  without  that  emotional  basis  which, 
the  maniac's  violence  always  has.  Their  speech  is  verbose 
but  the  sentences  are  without  connection  and  sense:  in  fact 
the  logical  and  associating  bonds  are  altogether  wanting, 
and,  under  the  confused  medley  of  disconnected  acts  and 
words,  the  progressive  dementia  is  apparent  to  the  ex- 
perienced observer.  Even  to  the  inexperienced  observer 
the  expression  of  the  patients,  as  well  as  their  random  and 


I/O  INSANITY. 

confused  talk,   seem   the   outcome  of  a   silly  and  childish 

condition.     This  variety  is   known  as  active  or  agitated  de- 

incjitia  ;  it  is  a  sequel  of  mania  and  of  agitated  melancholia, 

r      and  is  progressive,  though  o    longer  duration  than  passive 

-^      dementia. 

Tliis  dementia,  in  which  fragments  of  delusions  and  de- 
lusive ideas  are  still  retained,  constitutes  a  transition  to  that 
secondary  form  of  chronic  insanity  which  some  have  called 
"chronic  mania,"  others,  "secondary  partial  insanity," 
and  which  still  others  have  unfortunately  classed  among 
the  "  monomanias."  It  is  observed  that  some  maniacs  as 
well  as  melancholiacs  lose  the  dominant  emotional  charac- 
ter of  their  insanity,  without  regaining  mental  health.  The 
mind,  in  other  words,  is  no  longer  stimulated  by  an  emo- 
tional state  to  construct  expansive  or  depressive  delusions; 
but,  on  the  other  hand,  it  loses  the  logical  power  to  correct 
the  delusions  formed  during  the  previous  period,  i.e.,  the 
primary  insanity.  These  consequently  remain  integral 
parts  of  the  patient's  psyche,  and  become  fixed  delusions. 
Unlike  the  delusions  of  the  monomaniac — which  are  also 
fixed — the  delusions  of  secondary  insanity  ivith  confusion  of 
ideas,  or  "  chronic  confusional  insanity,"  as  the  writer 
proposes  to  designate  this  disorder,  are  not  elaborate, 
not  defended  with  skill  and  a  show  of  judgment;  in 
short  they  are  not  truly  systematized.  The  delusions  re- 
semble ruins  left  over  from  the  destruction  of  the  more 
elaborate  and  multitudinous  if  less  fixed  delusions  of  mania 
and  melancholia,  around  which  the  gathering  tide  of  a 
slowly  progressing  dementia  rises,  till  the  assertion  of 
the  delusions  becomes  a  mere  parrot-like  repetition,  and  is 
finally  buried  under  that  same  levelling  sea  of  dementia 
which  closes  the  history  of  all  those  primary  psychoses 
entering  the  domain  of  the  secondary  deteriorations. 

The  weakening  of  the  logical  power  and  the  memory  ac- 
counts for  the  frequent  observation  in  these  patients  of  a 
change  in  their  sense  of  identity. 

In  marked  contrast  with  the  primary  insanities,  the 
chronic  deterioration  last  mentioned  shows  few  if  any 
anomalies  of  vegetative  life.  The  appetite  and  assimi- 
lation as  well  as  the  sleep  become  normal  or  nearly  so,  and 
not  unfrequently  the  patients  become  very  stout.  A  rapid 
increase  of  the  adipose  tissues  of  a  patient  who  is  becoming 
calmer  than  he  was  during  his  primary  period  of  mental 
disorder  is  hence,  not  without  justice,  looked  upon  as  a  sign 


SENILE   DEMENTIA.  I/I 

of  evil  augury.  All  recovering  maniacs  and  melancholiacs 
increase  in  weight,  it  is  true;  but  that  increase  is  usually 
compensatory  for  the  loss  of  weight  occurring  at  the  onset 
of  the  disease,  and  does  not  as  a  rule  go  further. 

While  the  general  nutrition  does  not  always  suffer  in  the 
terminal  deteriorations,  certain  trophic  disturbances  are 
quite  common.  Hsematoma  auris,  cutaneous  eruptions, 
premature  grayness,  and  fatty  and  fibrous  changes  of  the 
blood-vessels  are  frequent  accompaniments.  These,  like  the 
deep  structural  changes  in  the  nerve-centres,  are  collateral 
phenomena,  and  do  not  stand  in  a  direct  causal  relation  to 
the  insanity. 


//.  Division  of  the  First   Class.     Attacking  the  individuals  in  Essential 

Connection  with  the  Development  and  Involutional  Penods.  A*^ 

Senile  Dementi.^. 
Insanity  of  Pubescence. 


CHAPTER    IX. 
Senile  Dementia. 

Senile  de?nenfia  is  a  progressive,  and  primary  deterioration  of 
the  77iind  connected  with  the  period  of  involution,  but  exceeding  the 
ordina7-y  extetit  of  such  involution  to  a  pathological  degree. 

As  stated  in  the  seventh  chapter,  a  certain  degree  of 
mental  enfeeblement  is  an  ordinary  accompaniment  of  old 
age,  and  cannot  be  considered  pathological.  Simple  diminu- 
tion of  the  mental  powers,  and  the  intensified  conservatism, 
lethargy,  and  habits  of  economy  incidental  to  senility,  do 
not  constitute  a  true  insanity,  and  therefore  should  not  be 
called  dementia.  But  when  the  ordinary  limits  of  these 
conditions  are  exceeded,  when  lethargy  becomes  fatuity, 
when  conservatism  becomes  suspicion,  and  penuriousness 
provokes  delusions  of  attacks  on  propert}'',  the  senile  sub- 
ject is  the  victim  of  an  insanity  which' is  only  found  with 
the  aged,  and  is  therefore  called  senile  dementia. 

Senile  dementia  is  to  be  considered  as  an  entirely  distinct 
conception  from  "senile  insanity."  Senile  insanity,  so 
called,  includes  senile  dementia,  but  senile  dementia  does 


172  INSANITY. 

not  include  all  of  senile  insanity.  Any  form  of  ordinary 
insanity,  such  as  mania,  melancholia,  dementia  from  active 
organic  disease,  and  monomania,  may  be  found  in  the  aged, 
and  present  at  least  in  the  main  the  features  which  char- 
acterize these  affections  at  other  periods  of  life.  There  is, 
indeed,  no  need  for  discriminating  between  senile  and  other 
periods  of  life  as  far  as  the  ordinary  forms  of  insanity  are 
concerned.  There  is  no  senile  mania  any  more  than  there 
is  a  middle-age  melancholia  or  an  adolescent  stupor,  and  it 
is  best  to  speak  of  the  ordinary  forms  of  insanity  as  mania, 
melancholia,  or  monomania  in  a  senile  subject.  The  only 
characteristic  form  of  senile  insanity  is  the  one  now  about 
to  be  considered.  Senile  dementia  should  not  be  confounded 
with  other  conditions  occurring  in  old  age,  of  which  men- 
tal enfeeblement  may  be  a  symptom.  There  are  certain 
gross  organic  diseases,  affecting  the  brain  in  advanced  life, 
which  produce  a  set  of  symptoms  often  and  improperly 
classed  as  senile  dementia.  Thus,  an  old  person,  after  a 
paralytic  attack  due  to  haemorrhagic  or  necrotic  brain  lesion, 
may  become  feeble-minded,  forgetful  of  the  proprieties, 
morbidly  irritable,  and  filthy  in  his  habits.  Such  a  condition 
is,  however,  a  complication  of  what  is  commonly  recognized 
as  an  ordinary  brain  disorder,  which  may  produce  similar 
results  at  any  period  of  life;  there  is  nothing  essentially 
senile  in  its  character,  although  it  is  more  frequent  in  the 
senile  state,  because  the  conditions  causing  it  are  more  com- 
mon in  the  aged  than  in  the  young.  Paralytic  and  epilepti- 
form seizures  may  be  accompaniments  of  senile  dementia, 
but  in  that  case  they  are  epiphenomena,  and  not  essential 
features  of  that  psychosis;  this  disorder  begins  as  a  senile 
dementia,  and  is  not  secondary  to  other  affections,  as  are 
the  forms  of  dementia  from  coarse  organic  disease  just  al- 
luded to.  Senile  dementia  is  to  be  attributed  to  a  slowly 
progressing  marasmus  of  the  nervous  tissues  transcending 
the  ordinary  degree  of  intensity;  to  which  more  active 
nutritive  changes,  in  the  way  of  encephalomalacia  or 
haemorrhage  may  or  may  not  be  added.  The  complicating 
dementia  occurring  in  old  age  after  coarse  disease  referred 
to  above,  and  which  is  distinct  from  it,  is  constantly  and 
characteristically  associated  with  such  coarse  disease. 

Senile  dementia  is  manifested  by  an  increased  egotism, 
or  by  penuriousness,  which  sometimes  reaches  such  a  degree 
that  the  millionaire  may  starve  in  the  midst  of  his  or  her  mil- 
lio.ns,  and,  though  residing  in  a  palace,  grovel  in  filth.     The 


SENILE   DEMENTIA.  1 73 

memory  becomes  enfeebled,  particularly  with  regard  to 
recent  events,  while  those  of  an  earlier  period  of  life  may 
be  well  remembered.  It  thus  happens  that  senile  dements 
frequently  lose  their  way  in  the  streets,  do  not  recognize 
their  own  houses  and  apartments,  and  cohfound  the  prop- 
erty of  others  with  their  own.  Prejudices  are  formed  on 
trivial  grounds,  or  on  no  grounds  at  all  ;  and  wealthy 
senile  dements  have  in  all  ages  been  made  the  subjects  of 
speculative  and  designing  persons,  to  the  detriment  of 
their  real  interests  and  of  tliose  who  were  the  subjects  of 
their  natural  affection  in  the  healthy  period  of  these  patients' 
lives.  As  the  disorder  advances  the  memory  continues  to 
decrease ;  the  incidents  of  whole  years  seem  to  be  blotted 
from  the  mind;  and  patients  have  been  known  to  forget  the 
names  and  number  of  their  children,  or  even  that  they  had 
been  married  when  such  was  the  case.  A  profound  moral 
deterioration  is  frequently  a  marked  accompanying  feature. 
Coarse  and  vulgar  expressions  are  used  by  persons  pre- 
viously accustomed  to  select  language,  or  the  patient  be- 
comes filthy  or  intemperate  in  his  habits,  and  assaults  or 
scolds  his  children,  treating  them  and  the  servants  like 
dogs.  To  this  there  may  be  added — particularly  in  male 
persons — a  pathological  sexual  desire,  a  senile  satj'riasis, 
which  with  some  manifests  itself  in  indecent  assaults  on 
young  girls  or  even  on  infants,  and  with  others  in  absurd 
and  ridiculous  marriage  plans. 

While  some  senile  dements  exhibit  delusions  of  an  am- 
bitious character — always  unsystematized,  however — the 
majority  have  depressive  delusions,  and  rare  instances  are 
on  record  where  senile  dements  have  committed  suicide, 
either  in  consequence  of  such  delusions,  or  because  they 
recognized  their  deteriorating  mental  condition. 

The  chief  and  most  common  delusions  of  senile  dements 
relate  to  their  property.  They  suspect  that  they  are  being 
defrauded  or  robbed  ;  in  consequence  they  take  what  they 
think  are  the  best  measures  to  prevent  defraudation  and 
robbery.  If  their  property  is  in  the  charge  of  an  agent, 
they  will  discharge  him  and  employ  another,  and  another, 
till  they  find  one  who  possesses  the  undesirable  qualifica- 
tions necessary  to  the  management  of  a  senile  dement — for 
experience  teaches  that  intrigants  and  time-servers  have 
had  more  success  in  this  direction  than  straightforward  and 
independent  business  men  or  the  honest  friends  of  the 
patient. 


174  INSANITY. 

The  anxiety  as  to  the  security  of  their  earthly  possessions, 
and  their  delusions  of  robbery,  produce  a  lachrymose  dis- 
position and  a  restless  and  purposeless  activity  in  these 
patients.  Some  of  them  roam  about  at  night  continuously, 
watching  for  thieves,  while  other  patients  do  so  without 
being  able  to  give  any  reasons  for  their  acts  whatever. 
Others  are  continually  engaged  in  devising  new  fastenings 
for  their  doors  and  windows,  and.  new  hiding-places  for 
their  treasures.  Hallucinations  and  illusions  may  compli- 
cate this  phase  of  senile  dementia,  and  the  patients  then 
cry  out  that  they  are  being  murdered,  robbed,  burned  up, 
cut  to  pieces,  or  poisoned. 

Should  no  other  inter-current  illness  cut  short  the  course  of 
the  psychosis,  bed-sores  and  colliquative  diarrhoeas  close  its 
history.  Sometimes  affections  of  the  bladder  are  very 
troublesome  toward  the  end  of  the  patient's  life,  and  may 
lead  to  fatal  cystitis  or  pyelitis;  indeed,  incontinence  of 
urine  is  one  of  the  most  constant  physical  accompaniments 
of  senile  dementia  from  its  inception.  If  the  patient  lives 
long  enough  complete  fatuity  sets  in;  he  may  then  become 
voracious  and  filthy,  to  finally  die  with  apoplectiform  symp- 
toms, or  with  those  of  a  gradual  and  general  paralysis. 
Aside  from  a  temporary  improvement,  which  is  exception- 
ally observed  in  those  cases  where  the  delusions  have  a 
melancholy  tinge,  the  progress  of  senile  dementia  is  chronic, 
and  consistently  in  a  downward  direction. 

The  physical  indications  of  extreme  age  are  always  found 
in  senile  dementia.  The  most  important  of  these  signs, 
because  it  is  related  to  the  cerebral  condition,  is  arterial 
sclerosis;  the  radials  are  hard,  giving  the  impression  to  the 
finger  of  a  tendinous  cord,  instead  of  the  normal  arterial 
resilience ;  with  this  the  temporals  are  tortuous.  Often 
there  are  observable  a  marked  arciis  senilis,  opacities  of  the 
vitreous  body,  and  sometimes  cataract,  as  expressions  of  a 
vitiated  state  of  nutrition.  An  invariable  symptom  is 
tremor,  but  this  does  not  differ  in  degree  from  that  which 
is  commonly  found  in  very  old  persons.  In  certain  patients 
marked  h)'peraesthesia  has  been  observed  by  Giintz,*  and 
vertigo,  anorexia,  paraparesis,  hemiparesis,  disturbances  of 
speech,  and  epileptiform  attacks  have  been  recorded  in 
others.  It  is  cases  presenting  these  symptoms,  which  are 
associated  with    more    considerable    cerebral    atrophy  and 

*  "  Allgemeine  Zeitschrift  fur  Psychia.trie,"  xxx. 


INSANITY   OF   PUBESCENCE.  1 75 

•nutritive  as  well  as  membranous  lesions  than  the  ordinary 
ones,  which  have  suggested  the  view  that  paretic  dementia 
is  a  pre-senile  involution  of  an  active  type. 

Of  2,297  patients  whose  form  of  insanity  was  made  the 
subject  of  a  statistical  study  by  the  writer,  82,  or  a 
little  over  three  and  a  half  per  cent,  were  classed  as  cases 
of  senile  insanity.  With  three  exceptions  these  were  all 
senile  dements.  It  may  be  assumed  that  the  proportion  of 
senile  dementia  is  much  greater  than  the  one  shown  by 
asylum  statistics,  as  only  the  agitated  and  troublesome 
patients  suffering  from  this  malady  are  sent  to  asylums. 


CHAPTER  X. 

Insanity  of  Pubescence. 

I7isanity  of  pubescence  is  characterized  by  mental  efifeeblement, 
marked  by  a  silly  disposition,  following  a  preliinitiaiy  period  of 
depression,  ivhich  has  the  same  tinge  as,  tvithout  the  depth  of,  that 
characterizing  melancholia,  and  tvhich  coincides  with  or  follows  the 
period  of  puberty. 

Probably  few  persons  pass  the  period  of  puberty  without 
manifesting  some  indications  of  the  profound  change  which 
the  mental  organism  undergoes  at  this  important  physio- 
logical crisis;  a  change  which  in  not  a  few  cases  is  a  real 
change  of  character,  without  being  for  that  reason — as 
those  who  define  insanity  as  essentially  consisting  in  a 
"  change  of  character,"  might  be  compelled  to  admit — an  in- 
dication of  mental  disorder.  Particularly  in  the  male  sex 
is  the  transition  between  the  childish  and  boyish  period 
preceding,  and  the  adult  period  following  puberty,  marked 
by  many  comical,  ridiculous,  and  even  disgusting  conflicts 
of  the  boy's  nature  with  that  of  the  coming  man.  The 
carelessness,  lack  of  judgment,  natural  egotism,  and  sport- 
ive tendencies  of  youth  are  out  of  harmony  with  the  aspi- 
rations and  feelings  which  now  develop  and  which  are 
destined  to  characterize  the  man.  The  result  of  their  union 
is  a  silly  ambition,  a  mawkish  sentimentality,  and  an  obtru- 
sive self-assertion,  which,  in  a  more  or  less  pronounced  de- 
gree, are  manifested  by  most  youths;  to  control  which  is 
one  of  the  main  objects  of  every  sound  educational  system, 


176  INSANITY. 

and  which  in  healthy  subjects  with  or  without  such  system 
are  soon  corrected  by  experience  through  its  incidental 
and  beneficial  hard  knocks. 

In  certain  rare  cases  this  correction  does  not  occur;  the 
patients  retain  the  absurd  notions,  the  silly  propensities, 
and  the  obtrusive  egotism  of  adolescence.  Whether  it  be 
the  existence  of  a  hereditary  taint,  or  masturbation,  which 
weakens  the  nervous  centres,  it  is  certain  that  the  transfor- 
mation of  the  childish  into  the  adult  character  is  arrested. 
This  is  the  essential  feature  of  the  hebephrenia  of  Hecker, 
the  "  insanity  of  pubescence"  of  Skae  and  Maudsley. 

This  psychosis  begins  with  a  period  of  sadness;  the  pa- 
tients are  depressed  without  being  able  to  assign  any  rea- 
son for  their  sadness,  and  suicidal  attempts  are  not  un- 
^frequenL  There  is,  howev'er,  no  deptli  to  the  depressive 
emotion  as  in  melancholia,  and  in  the  midst  of  the  de- 
pressed period  the  patients  appear  rather  obtrusive  in  com- 
municating their  sufferings  to  others,  and  will  not  hesitate 
to  simulate  in  order  to  awaken,  not  sympathy — which  they 
care  little  for — but  interest!  In  the  midst  of  these  periods 
they  maj^  suddenly  burst  out  in  causeless  laughter  or  even 
joke  in  a  silly  manner.  In  short,  the  contrast  in  the  char- 
acter of  the  changing  emotions  is  great,  but  the  emotions 
are  in  no  case  as  deep  as  in  the  mania  and  melancholia  of 
the  adult. 

After  this  preliminary  period  the  patients  exhibit  vague 
or  blind  propensities;  they  enter  a  business,  to  leave  it  the 
next  day,  wander  about  aimlessly,  or  display  a  stupid 
malice  toward  their  surroundings.  While  there  is  no 
incoherence  the  patients  manifest  a  peculiar  tendency  to 
adopt  verbose  language.  They  will  use  long  words,  or 
such  of  an  odd  sound,  or  ride  certain  grammatical  hobbies. 
Others  will  use  slang  or  foreign  expressions  and  quotations 
by  preference.  Gradually  the  condition  changes;  the  intel- 
lect weakens  progressively,  and  the  patient,  who  is  usually 
a  confirmed  masturbator,  will  pass  into  a  terminal  dementia 
marked  by  occasional  furious  outbreaks,  determined  in  their 
occurrence  by  his  unnatural  excesses  or  by  powerful  exter- 
nal impressions. 

Everything  connected  with  the  mental  state  of  these  pa- 
tients appears  shallow  and  even  unreal.  They  have  sham 
emotions,  sham  regrets,  sham  anger,  and  sham  complaints. 
Even  their  hypocrisy,  which  is  a  common  characteristic,  is 
shallow.     In  the  same  breath  in  which  they  affect  religious 


INSANITY   OF   PUBESCENCE.  I77 

aspirations  they  will  indulge  in  slangy  vituperation,  and 
then  break  out  in  causeless  laughter.  The  expression  of 
the  countenance  is  an  indication  of  the  condition  within;  it 
expresses  the  leading  character  of  lack  of  emotional  depth, 
silliness,  and  insincerity. 

The  course  of  this  form  of  insanity  is  protracted.  Enfee- 
blement  of  the  mental  faculties  is  noted  from  the  very  be- 
ginning, and  the  process  may  be  arrested  and  remain 
stationary  for  years  without  material  progress  toward  ter- 
minal dementia.  In  one  case  in  the  writer's  experience  a 
relative  cure  was  effected,  the  disorder  early  arriving  at  a 
standstill,  and  the  positive  characters  of  the  illness  disap- 
pearing. But  on  the  whole  the  prognosis  is  exceedingly 
unfavorable.  Imperfectly  developed  cases,  such  in  which 
the  disturbance  is  limited  to  a  slightly  strained  emotional 
condition,  with  a  tendency  to  writing  silly  and  extravagant 
poetry,  and  which  appear  to  be  merely  instances  of  a  path- 
ological intensification  or  undue  prolongation  of  the  ordi- 
nary pubescent  state,  present  better  prospects. 

Pubescent  insanity  has  been  observed  in  but  three  out  of 
one  hundred  and  eighty-seven  private  patients  by  the 
writer.  A  computation  from  the  statistics  of  a  pauper 
asylum  yielded  the  high  figure  of  nearly  five  per  cent  of 
cases  of  this  psychosis. 

As  indicated  by  its  name  pubescent  insanity  is  found  in 
subjects  between  the  fifteenth  and  twenty-second  years. 
Many  of  the  cases  are  still  classed  as  "  primary  dementia," 
particularly  when  the  deterioration  is  very  rapid.  Where 
masturbation  is  a  pronounced  feature  some  writers  use  the 
designation  "  insanity  of  masturbation."  In  reality  the 
masturbation,  although  a  frequent  accompaniment  and  per- 
haps a  result  of  hebephrenia,  is  not  its  cause,  however  much 
this  habit  may  ultimately  modify  the  character  of  the  psy- 
chosis. 


178  INSANITY. 


Second  Class  :   Simple  Psychoses  Associated  with  Demonstrable 
Active  Organic  Changes  of  the  Brain. 

Dementia  Paretica. 
Dementia  Syphilitica. 
Dementia   Organica. 
Delirium  Grave. 


CHAPTER  XI. 

Paretic  Dementia — Preliminary  Considerations, 

There  is  a  form  of  insanity  which,  from  its  constant 
assoication  with  the  classical  symptoms  of  ordinary  organic 
disease  of  the  brain  and  spinal  cord,  merits  most  attentive 
consideration.  There  have  been  thus  far  discussed  mental 
affections  whose  essential  characteristics  are  the  mental 
symptoms  proper.  We  have  found  that  with  most  of  these 
forms  of  insanity  disturbances  of  the  bodily  functions  are 
indeed  present;  but  these  are  rather  attendant  and  sub- 
sidiary phenomena,  of  importance  to  the  speculative  so- 
matic psychologist,  than  striking  features  of  the  insanity. 
In  short,  the  psychoses  thus  far  considered  could  be  defined 
and  recognized  in  a  crude  wa}'  without  taking  into  account 
the  coarser  bodily  conditions;  while,  with  the  psychosis  we 
are  now  about  to  treat  of,  this  is  different. 

Here  the  mental  symptoms  generally  present  the  picture 
of  unsystematized  ambitious  delusions,  combined  with 
progressive  paresis  and  dementia;  they  may  range,  however, 
from  atonic  depression  to  the  most  furious  delirium,  from 
the  construction  of  fanciful  projects  to  extreme  incohe- 
rency,  and  from  slight  and  almost  undemonstrable  mental 
impairment  to  the  absolute  extinction  of  higher  mental  life. 
In  like  manner  the  physical  signs,  whose  combination  with 
these  varied  mental  disturbances  is  essential  to  the  picture 
of  the  disease,  may  vary  from  slight  disturbances  of  speech 
to  gross  paralysis,  or  may  present  themselves  under  the 
mask  of  a  posterior  spinal  sclerosis  (locomotor  ataxia),  of  a 
disseminated  organic  disease,  or  of  apoplectiform  and  epilep- 


PARETIC   DEMENTIA.  1 79 

tiform  seizures.  Among  the  individual  signs  there  may  be 
found  almost  any  and  every  focal  and  general  symptom 
known  to  the  neurologist:  paresis  of  various  voluntary  and 
involuntary  muscles,  anaesthesias,  paraesthesias,  and  hyper- 
aesthesias,  pains  and  trophic  disturbances,  changes  in  the 
vascular  tone,  amblyopia,  hemiopia,  color-blindness,  and 
aphasia;  not  to  mention  choreiform  and  athetoid  move- 
ments, progressive  muscular  atrophy,  pseudo-hypertrophic 
and  bulbar  paralysis:  all  these  may  be  found  co-existent 
with  the  mental  disorder,  and  indeed  depending  on  the 
same  morbid  process  as  the  latter. 

In  the  case  of  no  other  form  of  insanity  are  the  patho- 
logical findings  so  constant  and  satisfactory.  It  may  be 
safely  asserted  that  in  all  advanced  cases  of  this  disease  a 
diffuse  lesion  of  the  brain,  sometimes  involving  other  parts 
of  the  central  nervous  system,  is  to  be  looked  for.  That  a 
disease  whose  pathological  basis  is  so  extensive,  affecting 
numerous  centres  in  varying  degree,  should  present  almost 
every  conceivable  variation  within  the  outline  of  symptoms 
just  drawn,  is  not  surprising.  That  the  mental  symptoms 
predominate  in  one  case,  the  motor  in  another,  and  the 
sensorial  in  a  third;  that  their  order  of  appearance  differs: 
in  some  instances,  disturbances  of  vision;  in  others  of 
speech;  in  others,  absent-mindedness,  fits  of  fury,  or  hypo- 
chondrical  tcedium  vitce  opening  the  history,  is  perfectly  nat- 
ural in  view  of  the  complexity  of  the  functional  role  of  the 
nervous  structures,  any  one  of  which  may  be  the  first  to 
weaken  and  break  down  under  the  diffuse  morbid  process 
of  this  disease.  With  the  recognition  of  these  facts  we  may 
waive  any  consideration  of  the  mooted  question,  whether 
paretic  dementia  is  a  simple  insanity  or  a  complication  of 
insanity  by  the  features  of  ordinary  central  nervous  disease. 
All  observers  are  now  agreed  in  considering  this  disorder 
as  a  primary  form  of  insanity,  existing  by  itself,  and  they 
attribute  to  its  physical  signs  the  same  value  that  is  as- 
signed to  its  mental  signs. 

This  disorder  is  known  by  a  number  of  names.  Some  of 
these  are  too  obsolete  to  call  for  mention  here,  and  the 
designation  employed  in  this  treatise  is  one  which  is  now 
gaining  ground,  particularly  in  England.  In  Germany  it  is 
known  as  dementia  paralytica  and  ^^progressive  Paralyse." 
These  terms  are  ambiguous,  for  the  dementia  sometimes 
accompanying  hemiplegia  has  been  earlier  known  under  the 
former  term;  and  while  the  objection  is  a  finical  one.  yet 


l80  INSANITY. 

it  has  been  raised,  that  the  affection  is  only  in  very  rare 
instances  evenly  progressive,  being  generally  marked  like 
that  similarly  progressive  affection,  locomotor  ataxia,  by 
exacerbations  and  latent  periods.* 

About  two  facts  there  can  be  no  dispute  or  quibble,  that 
the  essential  and  constant  feature  of  the  disease  is  demen- 
tia, and  that  it  is  associated  with  paresis  of  certain  muscles. 
These  features  are  hence  incorporated  in  one  term,  which 
is  as  little  ambiguous  as  it  can  be  made.  The  only  other 
affections  to  which  the  same  designation  might  apply  are 
syphilitic  dementia f  and  dementia  from  coarse  organic 
disease. 

Paretic  dementia  is  a  very  common  affection,  more  frequent 
in  communities  whose  members  are  subjected  to  great 
mental  strain  than  in  those  whose  members  are  engaged 
in  mechanical  pursuits  or  are  able  to  indulge  in  a  dolce 
far  niente. 

Of  2,297  male  patients  at  the  pauper  insane  asylum  of 
New  York  city,  284,^  or  a  little  over  twelve  per  cent,  were 
paretic  dements,  or  dements  with  organic  diseases.  In  the 
same  statistics  the  writer  found  that  the  nationalities  re- 
presented by  a  small  quota  of  the  asylum  population,  such 
as  the  Scandinavians,  Dutch,  Scotch,  Italians,  and  Sclaves, 
had  a  larger  proportion  of  their  insane  among  the  paretic 
dements  than  the  nationalities  represented  by  larger  num- 
bers. This  excess  is  attributable  to  the  facts,  that  the 
members  of  wandering  professions,  such  as  agents,  sailors 

*  Paretic  dementia  also  passes  under  the  names  " general  paresis," 
and  "general  paralysis."  The  alienist's  position  with  regard  to  these 
terms  is  similar  to  that  above  stated  as  the  one  held  with  regard  to  the  use 
of  the  adjective  "progressive."  No  scientific  alienist  will  misunderstand 
the  term  "  general  paresis,"  he  will  recognize  it  as  a  legitimate  label  for  a 
well-marked  affection.  But  he  will  abandon  its  use  after  being  met  on  the 
witness-stand,  as  the  writer  was  in  the  Gosling  case,  by  an  opponent 
who  states,  amid  the  tumultuous  applause  of  the  court-room  crowd,  and 
the  commendatory  glances  of  the  "intelligent"  jury,  that  there  is  no 
general  paralysis  except  in  death.  Popularly  the  disease  has  been  called 
"  softening  of  the  brain,"  and  is  diagnosticated  and  treated  as  such,  and 
is  hence  a  fruitful  field  for  the  charletan  to  this  very  day. 

f  Syphilis  found  as  an  accessory  etiological  factor  in  paretic  dementia 
of  the  typical  kind  does  not  justify  the  ranging  of  the  case  under  the  head 
of  syphilitic  dementia;  the  latter  is  a  clinically  and  pathologically  distinct 
affection. 

X  The  source  of  error  involved  in  the  confounding  of  syphilitic  and 
organic  dementia  is  not  sufficiently  great  to  affect  the  proportionate 
values  of  these  figures. 


PARETIC   DEMENTIA.  l8l 

or  firemen  on  board  of  steamers,  are  proportionately  num- 
erous among  those  of  these  nationalities  arriving  at  the 
port  of  New  York;  and  that  exposure  to  caloric  and  to 
syphilis,  two  potent  causes  in  the  etiology  of  paretic  de- 
mentia, are  very  common  with  these  professions.  The 
wandering  tendency  [inaiiia  errabunda)  of  paretics  may  also 
account  in  part  for  the  accumulation  of  paretics  of  foreign 
extraction  in  this  metropolis. 

Among  the  five  nationalities  or  races  represented  in 
large  numbers  in  the  asylum  mentioned  the  proportion  of 
paretic  dements  was  as  follows: 

Anglo-Saxons 13.29  in  100 

Celts H.5S  in  100 

Germans 1 1. 13  in  100 

Hebrews 10.29  in  i^o 

Negroes 8.82in  100 

It  is  here  seen  that  the  Anglo-Saxon  race,  the  race  of  the 
greatest  speculative  business  tendencies,  and  of  a  high,  if 
not  the  highest  intellectual  development  among  the  races 
inhabiting  the  United  States,  has  the  largest  percentage  of 
paretics.  That  mere  business  exertion  is  not  the  essential 
and  most  fertile  cause  of  the  disease  is  shown  by  the  fact 
that  the  Hebrew  race,  equally  as  active,  and  equally  if  not 
more  successful  in  the  mercantile  world,  occupies  one  of 
the  lowest  places  in  the  list.  That  intellectual  exertion 
per  se  is  not  a  cause,  is  shown  by  the  lesser  percentage 
among  the  Germanic  races,  who  have  always  stood  fore- 
most in  the  abstract  and  speculative  sciences.  Either  the 
high  proportion  must  be  directly  due  to  a  race  predisposi- 
tion or  to  some  inherent  tendency  of  the  race.  England 
and  America  are  the  lands  of  the  most  active  and  feverish 
progress  in  civilization,  of  great  facilities  for  rapid  travel, 
of  large  mercantile  and  manufacturing  establishments,  of 
hurry,  bustle,  and  restlessness  generally,  and  all  these  feat- 
ures seem  to  be  implanted  in  the  Anglo-Saxon  people. 
The  German,  on  the  other  hand,  still  retains  in  this  land 
the  so-called  phlegmatic  disposition  of  his  forefathers;  the 
Celt  preserves,  as  a  rule,  that  quality  for  which  he  was 
noted  in  his  native  island,  of  "taking  things  easier"  than 
the  Saxon;  and  the  negro  is,  as  a  rule,  indifferent  and  leth- 
argic in  those  matters  which  call  for  the  interest  and  action 
of  the  higher  races.  The  claim  that  there  is  a  constant  re- 
lation of  sexual  excesses  to  the  development  of  paretic  de- 


1 82  INSANITY. 

mentia  as  primary  causes,  contradicted  as  it  has  been  by- 
high  authority,  is  not  supported  by  these  figures.  No  one 
will  claim  that  the  Anglo-Saxon  is  more  libidinous  or  less 
able  to  endure  indulgences  than  the  other  races.  If  a  re- 
flection were  to  be  cast  on  any  race  in  this  respect,  it  would 
be  the  negro  race — which  shows  the  least  percentage  of  pare- 
tic dements — to  which  a  libidinous  character  might  be  as- 
signed. When  it  is  borne  in  mind,  too,  that  where  the 
negro  lives  under  conditions  natural  to  him,  and  where  he 
is  not  compelled  to  enter  into  competition  with  a  higher 
race,  paretic  dementia  is  almost  unknown,  the  conclu- 
sion will  seem  reasonable  that  paretic  dementia  is  more 
frequent  with  races  of  a  high  than  of  a  low  cerebral  organi- 
zation, because  their  higher  civilization  induces  a  restless 
mental  activity  with  its  attendant  emotional  strains,  and 
that  the  disease  is  hence  attributable  to  the  excessive  wear 
and  tear  of  the  brain  induced  by  such  civilization.  A  con- 
firmation of  this  view  is  the  fact  that,  while  paretic  demen- 
tia is  much  less  common  in  females  than  in  males,  it  is 
most  common  in  those  females  who  have  entered  into  com- 
petition with  the  male  sex  in  occupations  ordinarily  carried 
on  by  males.*  Paretic  dementia,  therefore,  is  not  as  some 
have  thought  a  penalty  of  high  cerebral  development,  but 
the  expression  of  a  discrepancy  between  the  instrument  and 
its  purposes;  in  other  words,  of  the  inadequacy  of  some 
brains  to  support  the  strain  to  which  the  race,  as  a  whole,  is 
subjected.  It  is  one  of  the  methods  by  which  the  contest 
for  existence  is  continually  being  decided  in  favor  of  the 
strong  and  against  the  weak;  and  its  greater  frequency  at 
the  present  day  is  in  harmony  with  the  fact,  that  the  con- 
test for  existence,  which  in  earlier  epochs  was  decided  on 
battle-fields  and  in  the  arena,  is  now  carried  on  more  large- 
ly in  parliamentary  halls,  in  the  bourse,  or  on  "  change,"  and 
with  the  pen  instead  of  the  sword. 

That  the  disease  did  not  exist,  however  rarely,  in  ancient 
times  is  not  demonstrated  by  the  fact  that  no  descriptions 
recognizable  as  those  of  cases  of  paretic  dementia  have 
been  handed  down  to  us  by  the  earlier  masters  of  medicine, 
as  is  so  frequently  urged  by  modern  writers.  If  this  rea- 
son is  to  stand,  then  we  must  assume  that  a  number  of 
disorders,  not  only  of  the  nervous  system,  like  "  spastic 
paralysis"  and  "  bulbar  paralysis,"  have  first  appeared  within 

*  Excluding  the  influence  of  alcohol  and  syphilis. 


PARETIC  DEMENTIA.  183 

a  few  decades,  but  that  many  diseases  of  a  general  nature, 
which  patliology  lias  recognized  the  existence  of  onlv 
within  the  last  few  years,  have  not  existed  prior  to  their 
discovery.  The  same  kind  of  argumentation  would  sup- 
port the  view  that  the  planet  Uranus  was  a  new  creation. 
It  should  be  borne  in  mind,  too,  that  many  of  the  statements, 
made  to  the  effect  that  paretic  dementia  is  on  the  increase, 
are  exaggerated,  however  true  the  general  tenor  of  this 
claim  undoubtedly  is.  In  many  of  the  asylums  in  the 
west  of  this  country  the  disorder  was  not  recognized  in 
the  tables  for  other  reasons  than  its  non-existence;  and  the 
widely-circulated  error  has  thus  gained  ground  that  the 
disease,  first  recognized  in  the  Bloomingdale  asylum,  is 
"  travelling"  from  the  East  to  the  West.  In  an  asylum  like 
that  at  Kankakee,  in  the  east  of  Illinois,  which  derives  its 
patients  from  a  largely  agricultural  population,  and  which  is 
one  of  the  institutions  in  which  a  scientific  classification 
has  been  adopted  and  is  carried  out,  the  proportion  of  paretic 
dements  given  in  the  tables  (6  in  424  patients  admitted  from 
1881-83)  is  not  quite  one  and  a  half  per  cent;  but  in  Chicago,, 
the  metropolis  of  the  same  State,  the  writer  is  assured  by 
competent  correspondents,  that  it  is  as  frequent  in  private 
practice  as  in  New  York.  Indeed  the  writer  found  a  toler- 
ably large  number  of  patients  in  the  pauper  asylum  of  New 
York  city  to  have  acquired  their  disorder,  as  they  had 
been  born  and  brought  up,  in  the  large  cities  of  the  West. 
It  is  not  safe  to  venture  too  far  in  speculation  on  the  ap- 
parent fact  of  a  rapid  increase  of  paretic  dementia  from 
year  to  year,  made  manifest  in  some  statistics.*  Where 
the  diagnostic  acumen  of  the  medical  officers  is  unques- 
tioned, as  in  the  large  German  and  French  asylums,  while  an 
increase  is  noticeable,  it  is  but  a  slight  one ;  in  some  cities,  as 
in  Hamburg,  it  is  actually  at  a  standstill,  and  in  one  year 
at  least  there  appeared  to  be  rather  a  decrease  in  this  place. 
But,  whatever  inferences  may  be  drawn  from  the  imperfect 
records  now  at  our  disposal,  there  can  be  no  question   that 

*A  student  of  the  writer's,  himself  an  asylum  physician,  visited  an 
asylum  in  one  of  the  Middle  States  in  which  about  a  fifth  of  the  male 
and  a  large  proportion  of  the  female  inmates  were  exhibited  to  him  as 
paretic  dements.  In  many  of  these  cases  nothing  beyond  an  emotional 
tremor  of  the  hands  could  be  advanced  to  justify  the  diagnosis,  and  it 
seemed  that  wherever  this  symptom  was  discovered,  particularly  if  there 
were  present  expansive  delusions,  no  matter  whether  these  were  syste- 
matized or  not,  the  diagnosis  of  paretic  dementia  was  made. 


1 84  INSANITY. 

one  of  the  great  problems  with  which  the  preventive  medi- 
cine of  the  future  will  have  to  deal  is  the  grappling  sue- 
cessfully  with  this  scourge  of  the  civilized  portion  of  man- 
kind. 


CHAPTER  XII. 

Paretic  Dementia,  its  Course   and  Symptoms, 

As  indicated  in  the  last  chapter,  paretic  dementia  in  its 
full  development  is  characterized  by  a  combination  of  men- 
tal and  somatic  deteriorations.  But  these  constitute  merely 
the  permanent  and  constant  background  of  the  disorder, 
on  which  we  may  find  developed  at  various  periods  of  the 
disease  and  in  bold  relief  almost  all  of  the  main  positive 
symptoms  of  insanity.  It  is  customary  for  purposes  of  con- 
venience to  divide  the  malady  into  stages  demarcated  by 
these  accessory  symptoms,  and  prominent  writers  on  the 
subject  have  established  three  such  :  a  first  stage,  marked 
by  moral  deterioration  and  other  changes  of  character  ;  a 
second,  characterized  by  exalted  delusions  ;  and  a  third,  in 
which  these  exalted  delusions  disappearing,  a  progressing 
mental  and  physical  failure  closes  the  history  of  the  disease. 
Others  speak  of  successive  stages  of  depression,  of  exal- 
tation, and  of  dementia.  But  while  there  are  a  number  of 
cases  in  which  these  stages  undoubtedly  exist,  there  are  a 
larger  number  in  which  they  are  not  sufficiently  well 
marked  to  justify  the  discrimination.  In  a  few  cases  the 
progress  of  the  disease  is  even  and  unmarked  by  exacer- 
bations, in  others  the  only  noticeable  symptoms  are  a  pro- 
gressing dementia  and  ataxia  with  paresis;  in  some  the 
physical  symptoms  are  prominent  from  the  beginning,  in 
others  not;  in  a  few  mental  deterioration  is  rapid,  in  most 
slow,  and  in  still  others  it  is  checked  and  retrogrades,  to  ad- 
vance again.  But,  however  much  the  disorder  may  vary 
with  regard  to  the  existence  of  separate  stages,  all  typical 
cases  have  a  well-marked  prodromal  period  whose  recogni- 
tion is  most  important  to  the  general  practitioner  of  med- 
icine ;  for  here  medical  treatment,  which  is  practically 
powerless  in  the  fully-developed  disease,  may  accomplish  a 
great  deal. 

The  Prodromal  Period  is  marked  by  so  insidious  a  de- 


PARETIC   DEMENTIA.  185 

velopment  of  the  symptoms  that  it  is  difficult  to  say  anything 
positive  as  to  its  duration.  The  writer  has  never  seen  a 
typical  case  in  which  these  symptoms  did  not  cover  a 
period  of  at  least  a  year.  In  the  majority  of  patients  ob- 
served in  private  and  consultation  practice,  and  where  the 
relatives  had  been  observant  of  the  approach  of  the  disease, 
it  was  determined  to  have  lasted  between  two  and  four  years. 
In  some  it  was  even  of  longer  duration,  and  in  one  case 
the  first  outbreak  of  the  illness  occurred  in  1877,  while  a  pre- 
liminary change  in  character,  occasional  amnesia,  purpose- 
less and  unprovoked  fits  of  fury,  and  hesitation  in  speech 
could  be  traced  back  to  1856.  Morel  speaks  of  patients  in 
whom  this  incubatory  stage  may  be  said  to  have  extended 
throughout  a  lifetime.  Undoubtedly  there  are  persons 
whose  career  is  marked  by  a  behavior  very  similar  to  that 
characterizing  the  paretic  dement.  Such  individuals  are 
full  of  extravagant  projects,  they  are  considered  "  hail  fel- 
lows well  met,"  being  generous  to  a  fault  with  strangers, 
though  tyrannical  and  breaking  out  in  causeless  fits  of 
anger  at  home.  The  most  prominent  feature  of  their  char- 
acters is  a  silly  boastfulness,  manifesting  itself  in  boyish 
claims  of  superior  qualifications  for  almost  every  and  any 
position  in  life.  In  the  case  of  an  intelligent  merchant  in 
good  social  standing,  whose  generally  excellent  mental 
training  was  manifest  even  in  the  deteriorating  period  of 
his  disease,  this  tendency  showed  itself  in  an  ambition  to 
acquire  physical  prowess  and  to  become  known  as  a  pugilist. 
He  frequented  taverns  and  other  low  places  of  amusement, 
became  an  intimate  friend  of  the  prize-fighters  Heenan  and 
Sayers  and,  as  he  paid  his  way  very  liberally,  was  allowed  to 
gain  easy  victories  in  the  various  encounters  which  he 
boastfully  provoked.  Such  a  "paretic  disposition"  must 
not  be  confounded  with  another  condition,  namely,  with 
primary  expansive  monomania  complicated  by  paretic  de- 
mentia, to  which  detailed  reference  will  be  made  later  on. 
(See  chapter  on  Diagnosis.) 

In  that  group  of  paretic  dements  whose  disorder  may  be 
designated  as  being  of  the  "spinal  "  or  ascending  type,  the 
symptoms  of  the  prodromal  period  are  such  as  precede  or- 
ganic disease  of  the  spinal  cord,  or  suggest  the  existence  of 
an  insidious  affection  of  the  entire  axial  portion  of  the  cen- 
tral nervous  system.  Pains  in  the  lower  extremities,  usually 
described  as  being  of  a  rheumatoid  character,  though  some- 
times of  the  dolorous  kind  found  in  locomotor  ataxia,  dou- 


1 86  INSANITY. 

ble  sciatica,  early  color-blindness,  belt-like  sensations  in 
various  parts  of  the  body,  particularly  the  head,  photopsia, 
tinnitus  aurium,  and  temporary  dotible  vision  are  the  chief 
of  these  symptoms.  In  the  "cerebral"  or  "descending 
torm,"  while  these  symptoms  may  coexist  in  a  less  prom- 
inent degree,  a  change  of  character  is  the  most  notable 
sign.  The  careful  business  man  becomes  negligent,  and 
the  good  father  or  husband  indifferent  to  his  family.  Fre- 
quently the  patient  himself  notices  this,  and  becoming  mor- 
bidly emotional,  he  may  weep,  or  show  genuine  melancholic 
depression,  because  he  feels  his  brain  power  failing  and  can- 
not call  up  his  natural  affections  as  of  yore.  There  is  a 
great  similarity  between  this  condition  and  primary  men- 
tal deterioration.      (Chapter  VII.) 

All  the  mental  symptoms  of  this  period  are  attributable 
to  simple  brain  failure.  The  attention  is  not  as  readily 
aroused,  and  the  patient  engages  in  conversation,  and  after 
a  prolonged  harangue  of  the  one  speaking  to  him,  inter- 
rupts him  with  the  exclamation,  "  What  did  you  say  ?  I  was 
not  listening."  This  inattention  is  not  the  inattention  of 
an  abstracted  normal  mind  which  is  able  to  recall  the  sub- 
ject of  its  abstracted  reverie  ;  for  the  paretic,  while  not 
hearing  what  his  friend  said,  cannot  tell  what  he  was 
thinking  of  that  occupied  his  attention.  That  faculty  has 
become  entirely  dormant  for  the  time  being,  and  the  pa- 
retic's abstraction  is  only  a  lesser  degree  of  another  symp- 
tom commonly  observed  at  this  period,  nameh^  a  tendency 
to  fall  asleep  in  the  middle  of  the  day,  in  the  counting- 
house,  and  particularly  after  meals,  or  at  lectures  and  en- 
tertainments. 

Amnesia  is  noted  from  the  beginning.  At  first  the  failure 
of  the  memory  relates  to  trifles;  the  patient  does  not  recol- 
lect whether  he  has  wound  his  watch,  and  may  wind  it 
half  a  dozen  times  one  day  and  not  at  all  on  the  next.  He 
may  forget  to  button  his  clothes,  to  pay  for  his  meals  at 
restaurants,  or  to  take  his  purse  with  him  on  leaving  the 
house.  More  serious  omissions  and  errors  are  made  as 
the  prodromal  period  progresses  :  the  business  man  makes 
wrong  entries,  or  omits  to  record  important  items;  and  the 
cases  of  two  physicians  are  related  by  medical  jurists,  one 
having  in  this  period  of  paretic  dementia  prescribed  i6  gr. 
of  tartar-emetic  instead  of  -^  gr.,  while  the  other,  a  Russian 
doctor,  was  sent  to  Siberia  for  having  caused  the  death  of  a 
colleague  by  a  similar  error.     In  his  "empty  abstraction" 


PARETIC   DEMENTIA.  187 

the  patient  may  take  the  wrong  train,  or  a  car  going  in  the 
opposite  direction  to  the  one  he  should  take  ;  and  is  partic- 
ularly apt  to  neglect  appointments.  These  acts  may  be 
committed  by  persons  normally  abstracted,  and  some  of 
them  are  habitually  committed  by  those  who  have  failed  to 
cultivate  systematic  habits  ;  their  diagnostic  importance  in 
the  case  of  a  paretic  dement,  therefore,  lies  solely  in  the 
fact  that  they  constitute  a  persistent  change  from  the  pa 
tient's  previous  and  normal  condition. 

In  this  stage  thefts  are  very  apt  to  occur,  in  some  cases 
with  a  quasi-cx\vci\\\3\  intent ;  in  others,  merely  from  forget- 
fulness.  Thus  a  patient  will  pick  up  an  article  to  look  at  it, 
and  then  pocket  it  in  his  abstraction.  Sometimes  forgeries 
are  committed  with  considerable  skill  by  previously  upright 
business  men,  owing  to  their  loss  of  moral  tone;  at  other 
times  useless  as  well  as  valuable  articles  are  stolen  in  a 
stupid  and  random  way.  Brierre  de  Boismont  relates  the 
case  of  an  old  government  officer  who  for  eight  years  prior 
to  his  reception  in  an  asylum  had  been  guilty  of  repeated 
abstractions  of  articles  at  public  sales  which  he  attended 
officially.  His  insanity  was  not  suspected  until  several 
months  before  his  interdiction.  On  the  occasion  of  the  last 
theft  he  was  arrested,  and  Brierre  de  Boismont  examined 
him.  On  entering  the  room  this  physician  immediately 
saw  what  kind  of  a  patient  he  had  to  deal  with;  he  had  the 
embarrassed  pronunciation,  "  petrified "  face,  heavy  walk, 
in  short,  the  characteristic  signs  of  paretic  dementia.  On 
being  interrogated  as  to  the  circumstances  of  his  arrest  he 
answered,  without  the  slightest  appearance  of  remorse  or 
shame,  "  the  people  who  put  me  in  prison  are  imbeciles, 
who  know  nothing  of  our  professional  usages;  it  is  the  cus- 
tom among  us,  a  custom  known  as  the  '  cote  G,'  to  choose 
some  object  of  slight  value  and  retain  it  when  taking  the 
inventory,  and  see,  here  are  two  which  I  thus  appro- 
priated." With  this  he  drew  from  his  pockets  a  handsome 
meerschaum  pipe  and  a  gold-mounted  tobacco  pouch.  The 
distinguished  physician  mentioned  pronounced  him  to  be 
suffering  from  paretic  dementia,  and  a  few  months  later  the 
patient  died  of  this  affection,  verifying  the  opinion.*  Simon 
relates  a  case,  presenting  a  similar  tendency  to  the  manu- 

*  "iiltudes  Medico-legales  Sur  la  Perversion  des  Facult6s  Morales  et 
Affectives  dans  la  Periode  Prodromique  de  la  Paralysie  Generale."  Paris, 
i860. 


1 88  INSANITY. 

facturing  of  stupid  excuses,*  at  a  later  period  of  the  disease. 
A  fisherman  who,  it  was  subsequently  ascertained,  had  pre- 
sented signs  of  paretic  dementia  for  half  a  3'ear,  was  de- 
tected emptying  the  nets  of  others,  and  appropriating  their 
contents.  He  was  first  beaten  by  the  owners,  and  then 
taken  before  court.  Here  he  declared  that  his  oars  had 
become  entangled  in  the  nets,  and  that  he  had  taken  the  fish 
out  in  order  to  rearrange  the  nets,  intending  to  replace  the 
former.  This  explanation  was  rejected  as  a  "cunning  eva- 
sion," and  the  physician  called  in  by  court  pronounced  him 
of  sound  mind,  notwithstanding  the  fact  that  the  prisoner 
had  been  suspected  to  be — and  tlie  suspicion  was  confirmed 
by  witnesses — insane  by  the  police  authorities  for  several 
months  previous.  Incidentally  to  his  other  declaration, 
the  prisoner  announced  the  characteristic  project  of  running 
a  net  across  the  Elbe  River,  to  be  dragged  by  two  steamers, 
thus  intending  to  catch  all  the  fish  at  one  swoop. 

Indecent  exposures  of  the  person  may  also  be  made,  in 
some  cases  from  satyrical  motives;  in  others  they  are  due 
to  the  forgetfulness  of  the  patient,  who  neglects  to  button 
his  trousers,  or  fails  to  bear  in  mind  that  he  is  exposed  to 
the  public  gaze.  It  must  also  be  borne  in  mind  that  the 
free  determination  of  the  will  is  gravely  impaired  in  paretic 
dements.  Chorinski,  one  of  the  Austrian  nobility,  was 
prevailed  upon  by  the  Baroness  Ebergenyi,  his  paramour, 
to  poison  his  wife.  A  few  years  later  he  died  a  paretic 
dement.  Several  instances  are  on  record  in  which  such 
patients  have  been  induced  to  marry  courtesans  or  other 
speculating  women,  in  some  instances  thereby  committing 
bigamy.  The  undue  influence  in  such  cases  has  the  way 
prepared  by  the  patient's  forgetfulness  of  the  fact  of  a  pre- 
vious marriage,  or  his  moral  deterioration. 

In  this  period  there  is  also  developed  a  morbid  irritability. 
The  previously  sedate  and  calm  head  of  the  famil)'-  will  fly 
into  a  furious  passion  on  hearing  of  a  trifling  loss,  a  slight 
expense,  the  breaking  of  crockery  at  table,  or  on  finding  his 
meat  overdone.  The  simplest  contradiction  will  cause  a 
fierce  denunciation,  or  even  a  violent  assault.  One  of  the 
first  observed  manifestations  in  one  patient  under  the  writ- 
er's care  was  the  throwing  of  a  large  bottle  filled  with  ink 
at  his  brother  and  business  partner,  on  the  latter's  asking 

*  "  Die  Gehirnerweichung  der  Irren"  (dementia  paralytica).  Hamburg, 
1871. 


PARETIC   DEMENTIA.  189 

him  the  meaning  of  a  certain  entry  in  the  ledger.  Impa- 
tient as  the  patient  is  of  contradiction,  he  is  impatient  in 
regard  to  other  little  matters.  One  paretic  dement,  who 
was  turned  out  of  a  theatre  because  he  was  unable  to  show 
his  ticket  (having  in  his  amnesia  forgotten  where  he  put 
it,  or  thoughtlessly  thrown  it  away),  broke  a  large  pane  of 
glass  to  climb  in  b}'  another  entry.  Another,  because  the 
atmosphere  of  a  carriage  seemed  too  close  for  him,  and 
finding  some  difficulty  in  opening  the  window,  took  his  cane 
and  broke  out  the  glass.* 

With  all  this  irritability  in  regard  to  the  little  affairs  of 
life,  the  patient  is  singularly  apathetic  with  reference  to 
more  important  matters.  A  patient  who  threw  a  knife  at 
the  servant,  because  she  took  his  plate  away  before  he  had, 
as  he  alleged,  finished  dining,  heard  unmoved  a  few  hours 
later  of  the  collapse  of  a  large  business  undertaking,  which 
involved  a  loss  to  him  of  over  a  hundred  thousand  dollars. 
It  is  remarkable  how  frequently  a  patient,  who  has  perhaps 
brutalh^  abused  his  wife  and  children  for  calling  in  a  phy- 
sician to  prescribe  for  him,  on  finding  that  a  carriage  drive, 
undertaken  at  the  suggestion  of  some  friend,  terminates  at 
the  asylum  in  which  he  is  to  be  confined,  hears  the  news 
without  manifesting  the  slightest  feeling  or  making  any 
protest  whatever.  In  one  case,  the  day  before  the  commit- 
ment, a  patient  of  the  writer's  had  had  a  physical  encounter 
with  an  expressman,  for  leaving  one  of  his  trunks  on  the 
street  instead  of  immediately  carrying  it  in;  on  finding 
himself  within  the  walls  of  Bloomingdale  he  walked  up  to 
the  scales  to  be  weighed  with  an  air  of  bravado,  and  said  to 
his  companions  that  they  should  also  avail  themselves  of 
the  chance  of  being  weighed  gratis. 

Irritability  which  breaks  out  on  slight  provocation  is  a 
sign  of  a  weakening  of  inhibitory  power  and  of  a  general 
loss  of  nerve  tone.  The  reverse  of  the  condition,  described 
by  Wundt  as  the  normal  one,  is  hence  found  in  paretic 
dementia.  A  healthy  person  displays  a  sanguine  tempera- 
ment in  regard  to  the  lesser  affairs  of  life,  the  melancholy 
temperament  in  the  serious  phases  of  his  career,  is  choleri- 
cal  in  connection  with  events  which  most  deeply  affect  his 
interests,  and  should  be  immovably  phlegmatic  in  carrying 


*  Both  of  these  patients  were  brought  before  juries  on  a  habeas  corpus, 
and  these  acts  were  successfully  paraded  before  the  laity  as  rational 
ones. 


190  INSANITY. 

out  his  intentions  after  these  are  deliberately  formed.* 
The  paretic  dement,  on  the  contrary,  is  cholerical  with  re- 
gard to  the  petty  affairs  of  life,  phlegmatic  at  important 
turning-points  in  his  career,  and  sanguine  with  regard  to, 
as  well  as  easily  diverted  from,  the  carrying  out  of  his 
purposes. 

It  is  in  harmony  with  the  readiness  with  which  paretic 
dements  may  be  controlled  by  their  surroundings  that, 
under  the  influence  of  "jolly  companions,"  they  become 
spendthrifts,  while  they  may  be  penurious  misers  at  home. 
And  it  is  an  evidence  of  the  frailty  of  their  purposes,  and 
the  readiness  with  which  they  may  be  diverted  from  them, 
that  although  many  paretic  dements  develop  suicidal  inten- 
tions in  their  depressive  moods,  they  very  rarely  carry  them 
out. 

Simultaneously  with  the  memory,  will,  and  emotional 
balance,  the  morals  begin  to  totter.  Often  moral  alienation 
is  the  most  prominent  of  the  earlier  symptoms  of  the  dis- 
order. Just  as  the  paretic  becomes  irregular  in  his  habits 
generally,  unpunctual  in  business  hours,  and  forgets  his 
appointments,  he  loses  sight  of  the  proprieties  and  of  his 
moral  obligations  to  his  family  and  to  society.  Just  as  he 
becomes  careless  in  the  spelling  of  words,  he  begins  to  use 
improper  ones  in  conversation,  employs  lewd  language  be- 
fore females,  and  oaths  as  expletives  in  ordinary  conversa- 
tion. Sexual  and  alcoholic  excesses  are  now  indulged  in. 
The  previously  prudent  and  temperate  business  man  orders 
cases  of  wine  sent  to  his  office,  in  order  to  have  the  means 
for  indulgence  close  at  hand.  The  once  faithful  husband 
begins  amours  with  the  serving-maids  before  his  wife  and 
children,  or  goes  to  theatres,  to  balls,  and  shows  himself  in 
public  with  notorious  courtesans.  The  accompanying  ex- 
cesses, like  the  similar  ones  indulged  in  by  the  maniac,  pre- 
cipitate the  development  of  the  disease,  particularly  as  an 
intolerance  to  alcohol  is  one  of  its  early  and  marked  feat- 
ures. A  well-meant  remonstrance  leads  to  an  outbreak  of 
furious  violence,  the  intervention  of  the  police  or  other 
authorities  to  conflicts  with  the  latter,  and,  the  patient's 
disorder  being  consequently  recognized  as  a  mental  trouble, 
he  is  perhaps  sent  to  an  asylum. 

This  EXPLOSION  OF  THE  ACTIVE  PHASE  of  paretic  demen- 
tia is  commonly  marked  by  exacerbations  of  the  physical 

*  "  Psychologische  Physiologic." 


PARETIC   DEMENTIA.  I9I 

■signs.  The  slight  defect  in  the  movements  of  the  tongue 
and  lips,  hitherto  noted  only  at  times,  now  becomes  more 
permanent.  The  patient  finds  it  difficult  to  pronounce  par- 
ticularly the  explosive  and  hissing  sounds,  and  the  longer 
a  word  containing  such  sounds  is,  the  more  manifest  does 
this  difficulty  become.  In  addition  the  voice  changes,  be- 
coming hoarser,  and,  as  Marce  claimed,  those  patients  whose 
disease  is  due  to  alcoholic  excesses  exhibit  a  more  tremu- 
lous intonation  than  is  ordinary  in  paretic  dements.  The 
speech  defect  is  aggravated  by  the  increasing  amnesia  of 
the  patient,  and  he  often  employs  the  wrong  consonants — 
■"  b"  for  "  p,"  or  "  t  "  for  "  d,"  and  "  m"  for  "  n."  Later  on 
whole  syllables  are  suppressed,  and  it  is  difficult  to  decide 
how  much  of  the  speech  disturbance  is  really  ataxic  and 
how  much  is  amnesic  in  origin.  A  most  characteristic 
feature  is  the  associationof  other  and  normally  unnecessary 
movements  with  those  of  the  lips  and  tongue.  The  patient, 
when  about  to  speak,  moves  the  lips  as  if  to  fix  them  more 
firmly;  there  is  a  tremor  at  the  angles  of  the  mouth,  an 
exaggerated  and  spasmodic  movement  of  the  zygomatici, 
alternate  dilatation  and  contraction  of  the  nostrils,  the 
usually  habitual  corrugation  of  the  brow  increases,  and, 
after  all  these  preparations,  the  word  is  thrown  out  precipi- 
tately, as  if  it  had  had  to  force  its  way  through  some  im- 
pediment. 

With  the  speech  innervations  all  the  finer  motor  co-ordi- 
nations seem  to  suffer.*  The  patient's  walk  becomes  less 
steady  and  regular.  His  legs  are  thrown  wider  apart  to 
increase  the  basis  of  support,  and  such  motions  as  dancing 
and  skating,  et  cetera,  if  among  the  previous  accomplish- 
ments of  the  patient,  can  no  longer  be  executed.  The 
musician  forgets  his  notes  and  loses  the  mechanical  skill 
necessary  in  wielding  the  bow  of  the  violin,  in  executing 
rapid  tremolos  on  the  piano,  and  can  no  longer  regulate  the 
inflation  of  the  cheeks  necessary  in  playing  on  the  brass  in- 
struments. The  stenographer  becomes  unable  to  follow 
the  speaker  whose  words  he  is  to  report.  Watch-makers, 
engravers,  or  other  mechanical  artisans,  who  depend  on  the 
use  of  their  hands,  find  their  occupation  more  laborious, 
their  attention  tiring  easily,  and  their  fingers  failing  them, 
so  that  their  work  is  spoiled  or  clumsily  performed.     It  is 

*  One  patient,  a  ventriloquist,  lost  his  art  in  the  early  period  of  his 
illness. 


192  INSANITY. 

at  this  period  that  the  handwriting  of  the  patient  may  first 
present  the  characteristic  features  to  be  referred  to. 

The  hypochondriacal  ideas,  depressive  moods  of  the  pa- 
tient, and  complaints  about  head  symptoms,  if  they  existed, 
disappear  about  this  time  in  the  majority  of  cases.  A  sub- 
jective sense  of  power  and  general  well-being  takes  their 
place.  The  so-called  delusions  of  grandeur  then  manifest 
themselves,  and  are  often  coupled  with  morbid  projects  and 
extravagant  expenditures.*  Both  the  delusions  and  the 
resulting  projects  are  unsystematized,  and  in  this  respect 
widely  different  from  those  of  a  monomaniac;  they  resem- 
ble the  corresponding  symptoms  of  acute  maniacal  delirium 
in  many  features.  But  it  is  usually  easy  for  the  skilled 
observer  to  detect  the  lacunae  in  the  intelligence  behind 
the  veil  of  delirium  in  paretic  dementia;  whereas  in  the 
maniac  such  lacunae  do  not  exist,  except  temporarily  in 
maniacal  frenzy.  The  latter  condition  is,  therefore,  not 
always  distinguishable  from  the  similar  phases  of  paretic 
dementia. 


*  The  distinguished  French  alienist  Brierre  de  Boismont  was  called 
in  consultation  about  the  nervous  condition  of  a  wealthy  man,  whose 
mental  disposition  had  been  recognized  by  the  family  physician,  although 
the  patient  dissimulated  his  infirmity  pretty  well,  under  that  show  of 
reasoning,  specious  argumentation,  and  habitual  decorum  which  is  so 
apt  to  mislead  the  laity.  The  alienist  speedily  unearthed  his  prodigious 
vanity  and  egotism,  and  recognizing  that  the  patient  was  suffering  from 
the  prodromal  stage  of  paretic  dementia,  called  the  attention  of  the 
family  to  the  fact,  and  advised  them  to  be  on  their  guard  as  to  the  dis- 
posal which  he  made  of  his  fortune.  A  year  passed  without  his  hearing 
of  the  case,  when  one  day  the  gentleman  in  question  was  brought  to  the 
asylum,  after  a  scene  of  violence  which  nearly  cost  one  of  his  family  her 
life,  and  after  he  had  squandered  about  two  hundred  thousand  francs  in 
absurd  speculations. 

Hammond  (General  Paralysis  of  the  Insane,  with  Special  Reference  to 
the  Case  of  Abraham  Gosling  :  an  address  delivered  before  the  Medico- 
Legal  Society,  April,  18S0)  describes  the  following  characteristic  case: 
"  Another  undertook  the  task  of  buying  nearly  all  the  jewelry  at  Tif- 
fany's, and  only  stopped  when  the  proprietors,  becoming  alarmed,  refused 
to  sell  him  any  more.  This  man  took  the  jewelry  he  purchased  home, 
and  bedecking  his  wife  until  she  glittered  with  gems  from  head  to  foot, 
compelled  her  to  walk  up  and  down  before  him.  Then  he  drew  a  check 
for  $5,000,  and  gave  it  to  his  servant  who  returned  with  a  glass  of  water 
which  he  had  called  for.  When  I  was  sent  for,  the  patient  told  me  he 
was  going  to  Europe.  He  intended  to  make  the  voyage  over  in  the  Great 
Eastern,  and  would  charter  the  Scotia  as  a  tender.  He  would  pay  me 
$1,000,000  a  month,  and  he  would  have  a  corps  of  physicians  on  the 
vessels,  the  members  of  which  should  be  attired  in  a  uniform  of  blue 
velvet  with  diamond  buttons." 


PARETIC   DEMENTIA.  I93 

After  one  of  these  explosions  the  patient  may  become 
comparatively  calm  and  rational,  his  physical  signs  retro- 
grade, with  slight  exceptions,  and  the  only  remaining  men- 
tal defect  may  be  a  feebleness  of  judgment  and  a  difficulty 
experienced  in  sustaining  a  prolonged  mental  effort.  The 
relatives  of  the  patient,  with  whom  the  wish  is  father  to  the 
thought,  and  the  inexperienced  medical  adviser  may  regard 
him  as  entirely  recovered.  But,  after  a  more  or  less  pro- 
longed lucid  or  rather  para-lucid  interval,  the  patient 
breaks  out  in  another  fit  of  excitement  or  depression,  and 
this  may  recur  at  irregular  intervals;  so  that  the  history  of 
many  paretic  dements  is  a  series  of  asylum  sojourns,  sepa- 
rated by  intervals,  in  which  they  have  been  able  to  attend 
to  their  business,  or  have  travelled  under  the  advice  of  their 
friends  or  attendants.  But  with  each  attack  the  patient  is 
left  in  a  more  crippled  condition  bodily  and  mentally,  the 
resisting  power  of  the  brain  is  gradually  weakened,  and  the 
patient  sinks  lower  and  lower  on  the  down  grade  to  abso- 
lute dementia.  The  loss  of  the  finer  motor  co-ordinations 
is  succeeded  by  the  abolition  of  the  coarser  ones;  gross 
speech  defects,  or  absolute  aphasia,  ataxia  of  movement 
and  inability  to  write  mark  the  decline;  and  when  the 
latter  is  far  advanced,  the  slight  paresis  of  the  earlier 
period  becomes  so  much  intensified  that  the  patient  may 
be  unable  to  leave  his  bed.  The  trophic  disturbances, 
which  were  but  faintly  indicated  at  first,  as  a  herpes 
zoster,  for  example,  also  become  prominent,  and  frequent 
ly  terminate  the  patient's  life;  malignant  bed-sores,  fu- 
runcles, haematoma  of  the  lower  bowel,  diarrhoea,  gastric 
haemorrhage,  or  pulmonary  gangrene  may  then  supervene. 
Finally,  if  the  patient  escapes  or  survives  these  dangers, 
while  the  night  of  utter  mental  darkness  is  settling  on  him, 
so  that  he  is  unable  perhaps  to  utter  even  the  infantile  de- 
lusions of  grandeur  entertained  in  the  earlier  period,  he 
succumbs  to  apoplectiform  or  epileptiform  seizures  of  a 
kind  peculiar  to  paretic  dementia,  and  which  may  some- 
times mark  the  course  of  this  disorder  from  the  begin- 
ning. 

Throughout  the  latter  phases  of  paretic  dementia,  and 
aside  from  the  maniacal  exacerbations,  the  patient's  de- 
meanor is  marked  by  good-humored  self-satisfaction  in  the 
majority  of  cases.  He  is  consequently  generous  with  his 
imaginary  riches.  At  the  second  interview  the  writer  had 
with  a  paretic  dement,  whose  disease  was  a  complication  of 


194  INSANITY. 

a  pre-existing  monomania,  the  patient  offered  him  three 
(actual)  patent-rights  as  presents.  An  almost  characteristic 
feature  of  these  patients  in  their  quiet  intervals  is  their 
enthusiastic  and  demonstrative  greeting  of  strangers,  to 
whom  they  will  almost  invariably  state  that  they  are  in 
excellent  spirits,  and  in  the  best  possible  condition  of 
bodily  health.  "  Fat  and  saucy"  responded  a  paretic 
dement,  as  he  half-stumbled  and  half-swaggered  into  the  lec- 
ture-room of  the  college,  when  asked  how  he  was  getting 
along;  "all  right"  and  "first-rate"  are  the  usual  responses 
in  the  paretic  wards  of  an  asylum.  These  patients  are 
enthusiastic  admirers  of  anything  novel,  or  which  they  are 
unable  to  understand.  When  Obersteiner  tested  a  number 
of  lunatics  with  his  "  psychodonometer,"  *  while  the  me- 
lancholiacs  developed  ideas  of  persecution  based  on  the 
formidable  appearance  of  the  instrument,  and  the  terminal 
dements  remained  indifferent,  the  paretic  dements  were 
unable  to  find  words  extravagant  enough  to  express  their 
unintelligent  admiration  for  the  new  device.  The  writer 
has  often  found  the  exhibition  and  application  of  the 
sphygmograph  a  most  useful  means  for  securing  an  ex- 
amination of  a  refractor)'  paretic.  A  brief  explanation  of 
the  mechanism  of  some  medical  appliance,  such  as  the 
ophthalmoscope,  will  elicit  from  such  patients  the  declara- 
tion that  their.doctor  is  the  greatest  man  in  the  world — 
next  to  themselves  of  course — he  having  looked  "right  into 
their  brains."  Quackery  which  treats  these  patients  as 
sufferers  from  "  brain-softening"  consequently  finds  an 
occasional  votary  here,  and  the  writer  has  heard  no  more 
enthusiastic  praises  of  "static  electricity"  and  similar 
therapeutical  impositions  on  the  credulity  of  the  profession 
and  laity,  than  from  a  paretic  dement  who  had  been  treated 
by  these  means. 

But  not  all  paretic  dements  are  habitually  good-humored, 
self-satisfied,  and  "hail  fellow  well  met"  at  this  stage  of 
their  illness.  Some  remain  ill-natured  and  distrustful, 
when  they  were  so  before  their  illness,  and  many  are  more 
demonstrative  with  the  closed  fist  than  the  open  hand. 

Any  one  of  the  symptoms  hurriedly  related  in  the  fore- 
going may  be  prominent  at  one  or  other  stage  of  the  dis- 
ease, absent  in  a  few  cases,  and  appear  earlier  or  later  in 
the  histories  of  different  patients.     They  therefore   merit 

*  An  instrument  for  measuring  the  rapidity  of  the  mental  reactions. 


PARETIC   DEMENTIA.  I95 

detailed  consideration  before  we  proceed  to  consider  the 
varieties  of  the  disease. 

The  unsystematized  delusions  of  paretic  dementia 
have  from  the  time  this  disease  was  first  recognized  been 
assumed  to  be  always  of  the  expansive  kind,  and  its  constant 
and  unvarying  features.  But  this  view  is  erroneous.  It  is 
true  that  such  delusions  are  present  at  some  period  of  the 
illness  in  most  patients,  but  they  are  of  a  depressive  kind  in 
a  few,  while  in  some  very  exceptional  cases  no  delusions 
whatever  are  observed.*  When  present  they  are  almost 
pathognomonic.  The  patient  claims  to  be  the  most  power- 
ful, the  richest  and  ablest  man  in  his  community.  He  can 
raise  the  asylum  with  his  little  finger,  he  has  trunks  filled 
with  gold  in  every  city  in  the  Union,  he  is  married  to  all  the 
handsome  women  in  the  world,  can  speak  all  the  living  and 
dead  languages,  has  the  best-developed  sexual  organs  ex- 
tant, and  is  the  intimate  friend  of  every  contemporary  great 
man,  sometimes  himself  Napoleon,  Caesar,  Shakespeare, 
Grant,  Buffalo  Bill,  and  every  other  celebrity  in  one  person, 
and  the  fortunate  owner  of  numerous  patents.  The  follow- 
ing is  a  partial  list  of  the  *'  possessions"  of  a  paretic  dement, , 
who  had  at  one  time  been  a  stock-broker  in  Chicago: 

Six  trunks  of  gold  in  Chicago  at  $30,000  each $  180,000 

Patent  watch  per  year 50,000 

Patent  knife  per  year *. . .  75,000 

Four  trunks  of  gold  at  Governor's  Island  at  $16,000. .  64,000 

Stock  in  Chicago 1,200,000 

Patent  billiard  cue  per  year 15,000 

Real  estate  in  Chicago 184,000 

Real  estate  in  Washington 90,000 

Interest  in  Chicago 8,000 

Interest  in  Washington 19,000 

This  patient  made  at  the  time  few  or  no  errors  in  his 
arithmetic  and  spelling,  and  was  perfectly  competent  to 
compute  interest;  his  alleging  a  larger  amount  of  interest 
in  Washington  where  he  had  less  property,  and  his  assign- 
ing different  values  to  his  items  in  different  papers  show 
how  little  reflection  and  system  enter  into  such  delusions 


*  One  patient  in  the  writer's  experience  had  advanced  far  in  dementia, 
paresis,  and  ataxia,  without  manifesting  a  single  delusion  up  to  the  time 
when  it  was  deemed  advisable  to  commit  him  to  an  asylum.  This  is  the 
only  case  observed  by  the  writer  which  corresponds  to  the  descriptions  of 
paretic  dementia  without  delusion  given  by  recent  English  writers. 


196  INSANITY. 

as  elements.  The  lack  of  real  originality  in  the  delusions 
and  projects  of  paretic  dements  is  illustrated  by  the  fact 
that  in  this  case  the  "  patent  knife"  had  "four  blades,  one 
to  saw  with,"  the  "patent  watch"  "could  go  two  days  with- 
out being  wound  up,"  and  the  "patent  billiard  cue"  had  a 
"rubber  tip."  A  common  day-laborer  who  attended  the 
writer's  clinic,  alleging  that  there  was  some  kind  of  an 
animal  in  his  stomach,  claimed  that  the  female  patients  had 
all  remarked  the  peculiar  expression  of  his  eyes,  and  that 
he  was  generally  fancied  on  their  account.  With  an  air  of 
greater  secrecy  he  added  that  his  virile  member  was  two 
feet  long  and  nine  inches  in  diameter,  and  that  he  had 
forty-four  houses  in  New  York.  In  a  remission  which  fol- 
lowed, the  size  of  the  organ  in  question  gradually  "dimin- 
ished;" he  admitted  that  he  did  not  own  the  houses,  but 
had  a  lease  on  them,  and  later  still  he  claimed  no  extra 
allowance,  either  of  real  estate  or  anatomical  property,  be- 
yond the  ordinary  male  citizen.  Extravagant  ideas  relating 
to  sexual  matters  are  exceedingly  common  in  male  paretics. 
In  females  they  are  less  common,  and  when  present  usually 
devoid  of  the  lewd  tinge  characterizing  the  sexual  ideas  of 
the  male;  females  may  claim,  for  example,  that  they  are 
pregnant,  and  delivered  every  week  of  a  beautiful  child,  or  a 
child  with  gold  teeth,  or  some  other  valuable  addenda. 

These  deluspns  are  as  manifold  as  the  number  of  paretic 
dements  is  great,  but  they  have  the  common  characters  of 
extravagance  and  lack  of  system.  In  the  later  periods 
they  are  also  exceedingly  unstable,  and  vary  greatly  from 
day  to  day,  so  that  a  patient  who  had  ten  thousand  dollars 
yesterday  claims  to  have  a  hundredfold  that  amount  to- 
day, and  to-morrow  ma}'  find  no  figures  adequate  to  express 
his  wealth.  The  general  of  to-dayis  the  president  to-morrow, 
and  "God  above  all  other  gods"  the  day  thereafter.  One 
patient  lives  in  a  marble  palace  in  the  morning,  which  be- 
comes transformed  into  a  golden  one  by  noon,  and  if  a  con- 
versation with  him  is  kept  up  long  enough,  his  residence 
will  be  transformed  into  diamonds  before  he  gets  through. 
The  patient  wishes  to  be  whatever  he  believes  to  be  great 
and  powerful,  and  his  wish  is  speedily  gratified  by  the 
enfeebled  brain.* 


*  It  is  an  interesting  fact,  illustrating  that  the  aspirations  of  the  paretic 
determine  his  delusions,  that  the  wealthier  paretic  dements  in  the  writer's 
private  practice  have  not  displayed  as  extravagant  monetary  delusions  as 


PARETIC   DEMENTIA.  I97 

Simon  aptly  says  that  the  position  in  life  of  the  patient 
should  be  borne  in  mind  in  estimating  the  signification  of 
these  delusions.  Thus  the  claim  of  possessing  a  thousand 
dollars  by  a  pauper,  or  of  an  income  of  a  hundred  dollars  a 
week  by  a  common  day-laborer,  are  as  grave  delusions  of 
grandeur  as  the  belief  of  having  millions,  or  a  daily  income 
of  thousands  would  be  on  the  part  of  a  well-to-do  patient. 
Most  patients  having  such  delusions  are  given  to  delusive 
boasting  of  their  past  achievements.  A  Wall  Street  broker 
claimed  that  he  had  beaten  Jay  Gould,  Vanderbilt,  and 
Russell  Sage  at  every  point,  time  and  again.  Another 
boasted  of  his  adventures  with  wild  animals,  which  he  had 
torn  limb  from  limb  in  single  encounters.  The  anecdotes 
of  paretics  relating  to  their  physical  strength  are  generally 
embellished  by  the  most  brutal  and  offensive  details.  Thus 
one  whom  the  writer  took  to  an  asylum,  because  his  rela- 
tives did  not  venture  to  assume  the  responsibility  of  accom- 
panying the  powerful  and  excited  patient,  related  how  at  a 
previous  asylum  sojourn  he  had  seized  an  attendant,  hurled 
him  through  the  air  down  eight  flights  of  stairs,  and  at 
the  bottom  of  each  landing  had  jumped  on  his  victim,  till 
at  the  last  one  the  viscera  of  the  latter  "squirted  "  out  of 
the  mangled  body,  and  covered  the  walls  and  vestibule. 
The  story  was  of  course  entirely  fictitious;  one  of  the  first 
persons  at  the  asylum  whom  the  patient  greeted  with  cus- 
tomary paretic  hilarity  was  the  alleged  victim,  and  while 
the  account  of  the  "  massacre"  started  with  locating  the 
incident  at  the  top  floor  of  the  asylum,  where  the  patient 
had  once  been,  and  which  was  only  three  stories  high,  the 
scene  shifted,  even  while  the  victim's  body  was  on  its  way 
down  eight  flights  of  stairs,  to  the  vestibule  of  his  residence, 
which  was  four  stories  high;  finally  he  confounded  the  past 
with  the  present,  and  made  a  vigorous  pass  at  the  writer,  for 
which  he  as  vigorously  apologized.  The  boasts  of  a  military 
paretic  dement,  narrated  by  Mickle  in  his  instructive  trea- 
tise were  yet  more  extravagant  and  as  cruel.  "  He  said 
that  he  was  commander-in-chief;  that  the  queen  was  his 
mother;  that  he  went  with  her  in  a  yacht  to  Russia  to  see 
his  sister,  who  was  married  to  the  czar;  that  he  with  forty 
comrades  killed  10,000  Russians  at  the  Malakoff  tower,  and 


the  pauper  patients  at  the  city  asylum.  It  is  in  insanity  as  in  health: 
what  the  subject  has  he  cares  little  for;  to  get  what  he  has  not,  seems 
most  necessary  to  his  happiness. 


198  INSANITY. 

on  the  same  day  stripped  the  corpses,  dug  a  hole,  buried 
them,  and  sold  their  clothing  for  ^£20." 

In  one  case,  that  of  a  patient  whose  disorder  dated  from 
an  injury  by  a  shell  fragment  which  struck  his  head  at 
Bull  Run,  and  who  boasted  of  the  "  boys  of  Company  K," 
and  the  gold  and  guns  they  had  buried  at  Fort  Hamilton, 
the  writer  drew  out  the  admission  that  the  patient  knew  he 
was  boasting;  and  it  seems  that  sometimes  the  delusions 
are  merely  vague  assertions,  which  have  become  settled 
beliefs,  owing  to  the  enfeeblement  of  the  logical  power,  and 
consequent  inability  to  recognize  the  absurdit}^  of  the  boast. 

The  delusions  of  grandeur  are  usually  associated  with 
EXTRAVAGANT  PROJECTS.  One  patient  whom  the  writer 
saw  at  Meynert's  clinic,  a  Hungarian  hairdresser,  had  in- 
vested his  entire  fortune  in  buying  up  all  the  hair  in  the 
Austrian  empire  having  a  certain  rare  shade  of  gray.  He 
imagined  that  this  was  the  color  of  the  empress's  hair 
(which  at  the  time  was  raven  black);  that  by  having  the 
monopoly  of  the  hair  required  for  her  artificial  curls,  etc., 
he  would  necessarily  become  hairdresser  to  the  court;  and 
that  his  way  to  future  preferment  was  thus  opened.  A 
keeper  of  a  small-beer  saloon  proposed  to  build  an  enor- 
mous concert-hall  in  New  York,  in  an  out-of-the-way  part 
of  the  city,  and  to  engage  a  celebrated  prima-donna  at  a 
salary  of  $250  a  night  to  sing  there;  at  the  same  time  he 
advertised  the  "Jumbo  glass  of  beer,"  and  scattered  five- 
dollar  gold  pieces  among  the  street  boys.  A  Cuban  pa- 
tient, who  was  discharged  as  "  recovered^"  from  the  pauper 
asylum  of  the  same  city,  during  a  partial  remission  of  his 
illness  bought  several  gross  of  red  and  blue  pencils  to  dis- 
tribute among  his  fellow  patients.  Frequently  these  pa- 
tients propose  to  marry  all  the  fine-looking  women  in  a 
given  city,  country,  or  the  entire  world;  one  intended  to 
marry  a  specimen  of  each  race,  and  another  all  the  women 
with  eyes  of  a  hazel  color.  Occasionally  the  patients  claim 
that  they  are  acting  under  commands  from  God.  They 
may  then  order  the  instant  execution  of  all  persons  having 
red  hair  on  account  of  their  antipathy  to  such,  or  in  more 
favorable  moods  and  without  a  cent  to  their  names  donate 
several  million  dollars  to  charitable  institutions.  A  de- 
mented paretic  physician*  proposed  giving  a  lecture  on  the 

*  He  resumed  his  practice  and  continued  it  for  five  years,  though  when 
seen  in  the  street  by  the  writer  showing  the  characteristic  gait  of  his 
disease.     Since  then  track  of  him  has  been  lost. 


PARETIC    DEMENTIA.  I99 

"  Diamond  Cross,  for  the  benefit  of  the  Little  Sisters  of  the 
Poor."  For  this  purpose  he  was  going  to  hire  Steinway 
Hall  and  the  Academy  of  Music  (distant  from  each  other 
about  two  hundred  feet),  having  sold,  as  he  said,  ten  thou- 
sand tickets. 

The  incongruity  of  the  paretic's  schemes  is  very  well  il- 
lustrated in  one  of  Mickle's  cases:  the  patient  ordered  "  25^ 
pounds  of  tobacco,  half  a  dozen  of  eau  de  cologne,  four  con- 
certinas, a  paper  shirt  and  a  paper  cravat,  60^  dozen  pocket- 
handkerchiefs,  a  field-marshal's  uniform  and  baton,  1009 
boxes  of  hams,  26,000  pounds  of  currants,  a  stage  and  a 
carpenter."  To  pay  for  this  he  gave  an  order  for  ;^i5o,ooo, 
or  "more  if  necessary."  One  of  the  writer's  patients,  who 
had  been  prevented  from  accomplishing  a  suicidal  purpose 
by  his  wife,  drew  diagrams  of  a  tombstone  to  be  erected 
to  his  memory,  whose  inscription  recited  all  his  achieve- 
mento,  and  sang  the  praises  of  his  wife  for  saving  the  life 
of  so  valuable  a  citizen. 

Patients  having  such  delusions  and  entertaining  such 
projects  are  usually  as  vain  and  obtrusive  in  their  demeanor 
as  in  their  speech  and  writings.  Sometimes  the-delusions 
are  absent,  but  the  inflated  ideas  of  self-importance  are 
just  as  prominent:  a  subaltern  government  officer  believes 
the  land  will  go  to  ruin  unless  he  remains  at  his  post,  or  a 
cashier  threatens  to  resign  unless  his  dignity  and  impor- 
tance are  properly  recognized  by  the  directors  of  a  bank. 
It  is  characteristic  of  these  patients  that  there  is  nothing 
small  about  them.  Their  wives  are  the  handsomest  wives, 
their  children  the  "  smartest"  children,  their  friends  are  all 
great  men,  and  they  have  no  disposition  to  bother  about 
such  "trifles"  as  the  ordinary  daily  occupation  to  which 
they  owe  their  bread. 

As  already  stated,  the  delusions  of  paretic  dements  are 
not  always  expansive.  Even  at  the  height  of  the  typical 
disease  a  sudden  change  in  their  character  may  occur. 
The  patient  who  was  the  emperor  of  the  whole  world  yes- 
terday is  the  poorest  beggar  to-morrow;  the  God  of  yes- 
terday is  thrown  into  the  deepest  pit  of  hell  to-day;  he  who 
was  a  giant  of  more  than  mountain  height  suddenly  shrinks 
to  an  invisible  dwarf;  and  another  who  had  the  best  brains, 
a  stomach  that  could  accommodate  tons  of  the  rarest  deli- 
cacies, and  boasted  of  having  a  most  powerful  animal 
frame  the  night  previous,  wakes  up  one  morning  to  the 
discovery  that  his  brains  are  running  out  at  his  meatus 


200  INSANITY. 

urinarius;  that  his  stomach  is  gone — the  seat  of  cancer — 
or  gnawed  by  some  wild  animal;  that  his  bowels  are  im- 
pacted, and  that  he  is  as  physically  weak  as  he  is  mentally 
annihilated.  This  condition  was  by  the  French  termed 
"micromania,"  so  called  in  contradistinction  from  the  ordi- 
nary state  of  delusive  grandeur  or  "megalomania."* 

It  is  noteworthy  that  the  delusions  of  belittlement  in  pa- 
retic dementia  are  as  absurd,  extravagant,  unstable,  and  un- 
systematized as  those  of  aggrandizement. 

While  depressive  delusions  are  among  the  rarer  episodes 
of  the  fully-developed  disease,  they  are  common  enough  at 
its  earlier  stages;  indeed,  they  characterize  the  "hypo- 
chondriacal "  and  depressive  forms  of  the  malady,  and  to 
some  extent  are  developed  in  the  earlier  phases  of  the  dis- 
ease in  most  patients.  As  a  consequence  of  his  inability 
to  collect  his  thoughts  and  regulate  his  business  affairs 
such  a  person  alleges  that  he  has  ruined  or  beggared  his 
family,  when  this  is  not  true;  another  claims  that  he  is  all 
burned  up,  that  his  abdominal  cavity  is  being  scraped  out 
inside  by  some  mysterious  agency,  or  is  the  seat  of  the  ex- 
ploits of  "something  alive."  Hallucinations  of  smell  of  a 
disgusting  character,  and  "  magnetic"  or  gustatory  illusions 
modify  and  determine  these  ideas. 

Just  as  suddenly  as  the  extravagant  delusion  of  grandeur 
may  undergo  a  transition  into  a  depressive  one,  so  the  re- 
verse may  occur  here.  The  patient  who  has  been  bemoan- 
ing the  ruin  of  his  family  all  along,  some  morning  may 
scatter  money  among  the  boys  on  the  street;  he  who  was  a 
"  worthless  wretch,  physically  and  mentally,"  yesterday,  and 
suspicious  of  everybody  else,  fearing  that  he  would  be  ar- 
rested and  imprisoned,  to-day  addresses  all  persons  he 
meets  as  his  best  friends,  invites  them  to  gorgeous  ban- 
quets, or  offers  them  shares  in  his  extensive  mining  and 
railroad  undertakings.  A  patient  who  could  neither  eat 
nor  digest,  and  who  had  not  a  penny  in  the  world,  accord- 
ing to  his  statements  made  during  the  hypochondriacal 
period,  awoke  one  morning  with  the  project  to  get  up  a 
monopoly  of  the  entire  sardine  and  Bermuda  onion  trade 
in  the  world;  and  having,  as  he  alleged,  secured  it,  pro- 
posed to  eat  all  the  sardines  and  onions  himself. 

Hallucinations  and  illusions  are  much  more  common 
in  paretic  dementia  than  is  ordinarily  supposed.      Many  of 

*  Also  applied  to  expansive  monomania. 


PARETIC   DEMENTIA.  20I 

the  delusions  are,  as  has  been  already  hinted,  based  on 
faulty  sense  perceptions,  and  we  consequently  find  that  the 
hallucinations  of  an  unpleasant  character  are  found  in  the 
"  micromaniacal"  and  melancholy  phases  of  the  disorder,and 
those  of  an  exhilarating  nature  with  the  ambitious  deliria. 
They  are  overlooked  in  paretic  dementia  as  in  simple  ma- 
nia, owing  to  the  greater  prominence  of  other  symptoms, 
Mickle,*  the  first  who  has  systematized  the  study  of  these 
symptoms,  believes  that  at  some  period  of  the  disease  hal- 
lucinations occur  in  about  one  half  the  cases.  He  found 
that  visual  and  olfactor)''  hallucinations  were  most,  and  ol-  iZ<'<^^C(/C 
factory  hallucinations  least  common.  In  the  writer's  ex- 
perience auditory  hallucinations  and  illusions  were  most 
frequently  found,  next  those  of  the  tactile  and  visceral  sen- 
sations, then  those  of  sight,  and  lastly  those  of  smell,  the 
latter  in  rapidly  deteriorating  cases.  As  Mickle  says,  they 
"  are  often  variable,  unstable,  inconsistent,  being  usually 
less  fixed  and  systematized  than  the  hallucinations  of  manv 
of  the  insane  of  other  groups."  It  would  be  still  better  to 
say  that  they  are  more  like  the  hallucinations  of  mania,  al- 
coholism, and  melancholia  than  those  of  monomania.  The 
patient  hears  his  name  whispered  or  the  sounds  of  ap- 
proaching footsteps,  and  sees  people  with  ugly  counte- 
nances making  faces  at  him.  In  one  case  in  the  writer's 
experience  "  countless  frogs,"  whose  intestines  had  bulged 
out  from  the  vent  and  been  "stuffed  into  their  mouths," 
"  hopped  around"  the  patient.  Ver}^  frequent  are  the  visions 
of  heaps  of  putrefying  corpses,  which  are  often  associated 
with  corresponding  hallucinations  of  smell.  Sometimes 
voices  are  heard  commanding  the  patient  to  do  a  certain 
deed;  in  an  impure  case,  one  of  traumatic  paretic  dementia 
complicating  an  undetermined  pre-existing  mental  disor- 
der, the  patient  heard  voices  commanding  him  to  kill  some 
one,  in  order  that  he  might  himself  be  compelled  to  com- 
mit suicide. 

According  to  Mickle,  hallucinations  and  illusions  of  the 
sense  of  touch  are  manifested  as  ''faecal  lumps  adhering  to 
the  skin,  or  dirty  fluids  thrown  upon  it,"  and  the  illusions 
of  the  sense  of  touch  generally  are  apt  to  be  of  a  disagree- 
able nature.  In  one  case  of  the  writer's,  that  of  an  aged 
paretic  dement  who  had  advanced  spinal  lesions,  vermin 
were  complained  of,  which  he  alleged  the  superintendent 

*  Journal  of  Mental  Science,  October,  i88i,  and  April,  1882. 


202  INSANITY. 

had  bred  to  annoy  him.  On  admission  several  scabs  were 
found  in  his  vest  pocket,  which  he  carried  with  him  as  an 
antidote  to  similar  inflictions,  which  he  said  were  imposed 
on  him  before  his  admission.  More  frequent  are  the  sense 
disturbances  of  a  pleasurable  kind.  The  wall-paper  of  the 
patient's  room  is  changed  to  gold,  his  furniture  to  dia- 
monds, worthless  rags  and  scraps  of  paper  are  hundred- 
dollar  bills,  and  pebbles  and  fragments  of  glass  are 
diamonds.  Often  the  patient  sits  in  a  corner,  in  rapt  ec- 
stacy  over  the  kaleidoscopic  visions  of  heavenly  and  mili- 
tary pageants  doing  him  honor. 

In  the  writer's  experience  unpleasant  hallucinations  in- 
volving a  multiplicity  and  sameness  of  objects  are  indica- 
tive of  a  rapid  progress  of  the  disease.  In  one  of  the  most 
acute  cases  observed,  that  of  a  young  man  aged  twenty- 
two,  lights  were  seen  everywhere:  torch-light  processions 
across  the  island  on  which  the  asylum  was  situated;  boats 
on  the  river  covered  with  torch-bearing  soldiers;  and  whole 
regiments  carrying  lampions,  and  intending  to  march 
against  the  patient,  were  awaiting  transportation  across 
on  the  opposite  shore. 

Disturbances  OF  THE  SPECIAL  senses  and  visceral  inner- 
vations are  found  aside  from  those  just  mentioned.  Many 
paretics  become  amblyopic,*  in  consequence  of  central  pro- 
cesses or  affections  of  the  optic  nerve.  Others  suffer  from  per- 
manent or  temporary  hemianopsia,  due-to  cortical  disease  or 
dropsical  distension  of  the  third  ventricle.  Loss  of  smell 
(anosmia)  is  occasionally  observed  early  in  the  disease,  and 
becomes  usually  marked  as  the  morbid  condition  progresses. 
Voisin  is  decidedly  in  error  in  claiming  that  it  is  a  constant 
symptom  in  the  early  stages,  and  not  a  single  writer  agrees 
with  him  on  this  head.  An  insatiable  craving  for  food 
(bulimia),  which  is  noted  particularly  in  patients  with  con- 
siderable deterioration,  is  attributable  to  a  disturbance  of 
the  vagus  nerve;  v/hile  anaesthesia,  parsesthesia,  hyper- 
£esthesia,  analgesia,  or  hyperalgesia,  are  noted  in  those  cases 
in  which  the  spinal  disease  is  prominent,  and  they  some- 
times serve  as  the  basis  of  illusional  delusions.  Thus  one 
of  Mickle's   patients  believed  that  his  skin  was  tucked  in. 


*  In  a  will-contest,  the  Perrin  case,  tried  in  a  Western  State,  sclerotic 
degeneration  of  an  entire  occipital  lobe  was  reported  by  the  pathologist 
witness,  and  it  was  singularly  enough  omitted  to  bring  this  fact  into  con- 
nection with  the  amblyopia  noted  during  the  decedent's  life. 


PARETIC   DEMENTIA.  203 

another  that  it  was  hung  up  to  dry,  and  a  patient  of  the 
writer's  was  continually  picking  off  "gold  leaf"  from  his 
bodily  surface. 

The  EPISODICAL  ATTACKS  of  paretic  dementia  are  among 
its  most  important  signs.  They  are  of  three  kinds,  which, 
from  their  resemblance  to  maniacal  delirium,  epileptic  fits, 
and  apoplectic  seizures,  are  called  respectively  the  maniacal, 
epileptiform,  and  apoplectiform  attacks  of  paretic  dementia. 

The  nature  of  the  maniacal  attacks  of  paretic  dementia 
varies  with  the  period  at  which  they  appear;  for,  like  the 
other  episodial  outbreaks,  they  may  mark  the  disease  at  an 
earlier  or  a  later  period,  in  rare  cases  recur  from  the  begin- 
ning to  the  end,  and  in  still  rarer  cases  be  absent  altogether. 
It  is  evident  that  in  the  earlier  periods  before  the  mind 
has  undergone  deep  decay,  the  deliria  must  be  more 
creative,  the  flight  of  ideas  more  extensive,  and  a  chain  of 
reasoning  occasionally  visible  in  the  patient's  words;  while 
in  later  periods  the  fancies  of  the  sufferer  will  be  hampered 
by  the  dementia,  their  expression  checked  by  aphasia,  and 
reasoning  impossible,  because  its  essential  foundation, 
the  memory,  is  grossly  impaired,  and  the  association  of 
ideas  interrupted.  Meschede  reports  a  case  of  a  paretic 
who,  brought  to  the  asylum  early  in  the  disease,  suffered 
from  a  maniacal  attack  of  three  hours'  duration,  in  which 
the  flight  of  ideas  and  rapidity  of  speech  were  actually 
delirious.  He  did  not  interrupt  the  torrent  of  sentences 
which  issued  from  him  but  once  or  twice,  to  moisten  his 
parched  lips  with  a  little  water,  and  all  this  time  announced 
his  scheme  to  measure  the  orbits  of  the  planets,  thought  he 
was  determining  the  distance  of  the  dog-star,  undertook  to 
square  the  circle,  and  finally  gave  a  feast  to  the  whole 
world  of  truly  Arabian  Night's  profusion.  There  are  a  few 
cases  on  record  where  this  maniacal  condition  continued 
for  a  long  period,  or  even  marked  the  entire  course  of  the 
disease.  Such  cases  terminate  rapidly  through  maniacal 
exhaustion  or  other  complications,  and  have  been  desig- 
nated galloping  paretic  dementia.  In  others  there  is  a  sub- 
acute maniacal  condition,  analogous  to  hypomania  (p. 
136);  the  patients  then  are  not  actually  delirious,  but  display 
a  restless  activity,  often  leading  them  to  the  performance 
of  boyish  and  silly  acts,  such  as  dressing  themselves  up  as 
women.  A  noted  pantomime  actor  examined  by  Hammond 
first  manifested  his  disease  bv  hurling  loaves  of  bread, 
turnips,  cabbages,  and  other  objects  employed  in  the  pan- 


204  .  INSANITY. 

tomime  among  the  audience,  and  later  by  uniforming  a 
number  of  children  in  "  Humpty  Dumpty  "  costume,  intend- 
ing to  teach  them  his  art,  and  thus  to  perpetuate  it.  Just  as 
this  analogue  of  the  milder  attacks  of  mania  is  found  in 
this  protean  disease,  so  the  severe  attacks  of  maniacal  furor 
are  also  and  more  faithfully  copied  in  it.  The  furor  of  the 
paretic  dement  is  one  of  the  most  fearful  of  all  the  occur- 
rences of  the  asylum  ward.  Day  and  night  these  patients 
rave,  tearing  and  breaking  everything  within  reach,  besmear 
themselves  with  their  excrement,  or  even  devour  it,  and 
shout  at  the  top  of  their  voices.  They  yell  alternately  that 
they  are  being  murdered,  that  they  wish  to  get  out,  an- 
nounce the  most  extravagant  delusions,  claiming  that  they 
have  millions  on  millions  of  palaces,  all  the  wealth  of  the 
world,  can  lift  the  solar  system  with  a  finger,  or  threaten 
their  attendants  with  the  vilest  and  most  cruel  punish- 
ments. The  brutality  of  these  patients  is  something  re- 
markable. It  is  the  possibility  of  the  maniacal  attacks  oc- 
curring, and  the  great  likelihood  of  their  leading  to  vio- 
lent and  fatal  assaults,  that  should  be  borne  in  mind  by 
those  who  let  loose  such  patients  on  society  in  the  remis- 
sions of  the  disease. 

The  attacks  of  paretic  furor  last  a  few  hours,  days,  and 
occasionally  weeks,  and  may  cause  the  death  of  the  patient 
by  exhaustion;  particularly  when  they  recur  in  rapid  suc- 
cession. It  is  remarkable  to  what  extent  the  dementia  and 
certain  physical  signs  of  this  disease  may  be  masked  by 
these  attacks.  The  furious  paretic  dement  has  a  more  ex- 
tensive vocabular}^  more  expansive  ideation,  less  ataxia  and 
aphasia  than  he  had  during  the  previous  period;  and  one 
who  previously  was  bed-ridden,  or  tottered  about  the  wards 
with  the  characteristic  paretic  stagger,  now  steps  more 
firmly  and  destroys  heavy  doors  and  furniture.  One  night 
the  writer  was  suddenly  called  to  the  residence  of  a  de- 
mented paretic  patient,  and  in  the  absence  of  conveyances 
and  assistance  was  compelled  to  stay  up  with  him  until  the 
morning.  A  heavy  blow  was  the  first  greeting,  but  a  little 
art  elicited  a  characteristically  profuse  apology  from  the 
patient.  An  hour  before,  he  had  broken  the  panels  and 
driven  a  heavy  door  from  its  hinges  with  the  intention  of 
murdering  his  wife,  in  whose  behalf  he  subsequently  em- 
ployed the  writer's  medical  services,  and,  to  satisfy  a  sim- 
ulated hysterical  desire  of  hers,  tasted  the  medicine  she 
was  to  receive,  thus  taking  what  was  really  intended  for 


PARETIC   DEMENTIA.  20$ 

him.  He  had  attempted  to  set  fire  to  his  house  three  times 
that  night.  Subsequently  his  delirium,  which  toward 
morning  became  modified  and  diminished  by  the  conium 
and  hyoscyamus  given,  assumed  a  less  destructive  and 
more  expansive  character.  The  patient  went  over  his 
school  attainments  and  almost  every  boyhood  reminiscence 
and  event  of  his  life,  in  an  incredibly  rapid  speech  which 
lasted  eight  hours,  and  was  occasionally  marked  by  quite 
poetic  flights. 

In  some  cases  the  maniacal  explosions  are  followed  by 
stupor  or  aphasia,  and  complicated  by  the  attacks  to  be 
next  considered. 

The  EPILEPTIFORM  SEIZURES  may,  as  already  indicated, 
take  place  at  any  period  of  the  disease,  though  usually 
observed  only  near  its  termination.  In  the  following 
case  they  were  the  first  symptoms  noted,  and  had — what 
is  very  rarely  the  case — the  true  epileptic  character  :  A 
porter  in  a  down-town  warehouse  had  been  promoted  to 
a  higher  position,  greater  responsibilities  and  labors  of 
a  mental  character  were  thrown  on  him;  in  the  midst  of 
apparent  health,  having  been  slightly  "  worried,"  he  was 
seized  with  a  convulsion  lasting  several  hours,  with  partial 
consciousness,  and  later  on  these  convulsions  occurred  in 
status-like  succession,  at  intervals  of  a  week,  for  some 
months.  Eighteen  months  after,  the  convulsions  having 
been  absent  for  a  year,  he  died  with  the  "quiet  type"  of 
paretic  dementia.  In  another  now  under  observation  a  re- 
mission of  over  eight  months  followed  a  series  of  such  at- 
tacks. 

In  ordinary  cases  these  attacks  occur  after  motor  paresis 
is  already  indicated,  and  begin  as  imperfect  fits  of  the  clonic 
kind,  aft'ecting  the  muscles  of  the  face,  or  of  both  the  face  and 
arm,  on  one,  or  more  rarely  on  both  sides.  The  spasms  are 
not  usually  as  violent  nor  as  excursive  as  those  of  epilepsy, 
and  in  many  instances,  particularly  in  those  onsets  which 
last  for  whole  days,  resemble  a  convulsive  tremor  rather 
than  an  epileptic  fit;  consciousness  is  impaired  or  not  nota- 
bly affected;  at  times,  however,  an  initial  spasm  of  a  tonic 
kmd  is  observed,  and  then  there  may  be  well-marked  con- 
vulsive action  of  all  the  muscles  of  one  half  of  the  body  and 
conjugated  deviation  of  the  eyes  and  head  with  abolition  of 
consciousness.  The  appearance  of  a  patient  lying  for  many 
days  in  a  continued  convulsion  involving  all  the  muscles  of 
one  half  of  the  body  with  conjugated  deviation  is  one  of  the 


206  INSANITY. 

most  surprising  ones  experienced  by  the  novice  in  an  asy- 
lum. And  still  more  surprising  is  the  frequent  recovery  of 
the  patient  from  so  formidably  appearing  an  attack. 

Apoplectiform  seizures  may,  like  the  epileptiform  ones, 
inaugurate  the  disease  in  exceptional  cases.  Ordinarily 
their  appearance  is  heralded  by  "  congestive  spells."  The 
patient  having  for  some  weeks  observed  that  his  head  feels 
heavy  and  dull,  or  as  if  a  tight  band  encompassed  it,  after 
an  unusually  liberal  meal  or  a  slight  indulgence  in  alco- 
holic beverages,  experiences  a  sudden  rush  of  blood  to  the 
head;  his  face  becomes  crimson  or  purple,  the  temporals 
throb  violently,  and  for  a  moment  there  is  an  inability  to 
speak  or  to  collect  the  thoughts.*  These  attacks  may 
occur  in  the  midst  of  conversation,  and  while  the  continu- 
ity of  ideas  is  interrupted  by  them,  the  thread  of  thought 
is  resumed  when  the  normal  or  approximately  normal  con- 
dition of  the  circulation  is  re-established.  They  are  but 
momentary;  the  more  severe  ones  resemble  the  apoplex- 
ies f  due  to  extensive  cerebral  haemorrhages,  and  are  of 
longer  duration.  Here  the  patient  may  suddenly  fall  down 
as  if  struck  by  lightning,  and  the  entire  half  of  the  body 
may  then  be  found  limp  and  removed  from  the  influence  of 
the  will,  or  but  imperfectly  controlled  by  it.  These  apo- 
plectiform attacks  may  be  complicated  by  convulsions,  by 
tetantic  spasms,  moinemcnts  en  manege,  and,  as  Kiernan  was 
the  first  to  notice  (1S76)  in  a  case  shown  the  writer,  by 
athetoid  motions.  It  is  not  the  least  remarkable  feature  of 
the  strange  disease  we  are  considering  that  these  at- 
tacks, like  the  epileptiform  seizures,  are  often  and  rapidly 
recovered  from,  as  far  as  the  life  of  the  patient  and  gross 
motilit)'  are  concerned. 

The  effect  of  the  epileptiform  and  apoplectiform  episodes 
on  the  patient's  general  condition  is  disastrous.  Occurring 
as  they  often  do  during  the  remissions,  just  at  the  moment 
W'hen  the  patient  has  been  apparently  improving,  and  leav- 
ing him  more  or  less  enfeebled  or  aphasic  and  paralyzed, 
they  destroy  what  little  hope  as  to  a  delay  in  the  progress 
of  the  disease  may  have  existed. 

Although  no  invariable  rule  can  be  framed  it  may  be  as- 

*  A  condition  which  is  a  pathological  imitation  of  the  action  of  nitrite 
of  amyl. 

f  True  apoplectic  attacks  dependent  on  haemorrhage  do  occur  in  the 
terminal  stages.  Such  were  determined  at  \!a.^  post  mortem  of  three  of  the 
writer's  cases. 


PARETIC   DEMENTIA.  20/ 

sumed  that  those  paretic  patients  wlio  experienced  numer- 
ous syncopt4€  or  vertiginous  attacks  in  the  prodromal  period 
of  their  disease,  as  many  do,  will  be  more  likely  to  suf- 
fer from  epileptiform,  and  those  who  had  chiefly  congestive 
spells  and  "  word-stoppages"  will  have  apoplectiform  seiz- 
ures toward  the  end  of  their  lives.  Both  classes  of  attacks 
may  however  be,  and  frequently  are,  associated  in  the  same 
patient. 

Among  the  continuous  motor  disturbances  of  paretic  de- 
mentia those  of  the  pupil  merit  special  consideration.  Its 
most  characteristic  condition  in  this  disease  is  inequality, 
•due  to  paresis  of  the  circular  fibres  of  the  iris  of  one  eye, 
or  to  a  greater  degree  of  paresis  of  the  iris  of  the  side  where 
the  pupil  is  relatively  dilated.  Although  Lasegue  could 
•only  find  such  a  difference  in  one  third  and  Simon  in  one  half 
of  his  cases,  the  writer  is  inclined  to  believe  that,  on  com- 
paring— not  a  large  number  of  patients  simultaneously — 
but  their  records  extending  over  the  entire  history  of  the 
disease,  this  inequality  will  be  found  to  have  been  present 
in  the  majority  of  paretic  dements  at  some  time  or  other. 
The  inequality  is  usually  not  constant;  one  week  the  pupil 
of  the  right,  the  next  that  of  the  left  eye  may  be  the  nar- 
rowest, and  in  exceptional  cases  bilateral  dilatation  may 
alternate  with  bilateral  pin-hole  contraction.  In  some  cases 
extreme  pin-hole  contraction  is  noted  from  the  beginning; 
these  run  a  rapid  course,*  but  not,  according  to  the  writer's 
observations,  because  pachymeningitis  is  apt  to  be  present 
under  these  circumstances,  as  Simon  claims. 

In  one  patient,  whose  commital  to  an  asylum  was  made 
the  subject  of  litigation,  maximal  and  symmetrical  dilatation, 
with  normal  contraction  under  the  influence  of  light  and 
efforts  at  accommodation,  were  found.  His  symptoms  were 
of  the  typical  kind;  while  Simon,  who  observed  a  similar 
condition,  found  his  patient  to  have  symptoms  resembling 
those  of  apathetic  melancholia. 

An  extreme  dilatation  of  both  pupils  following  pin-hole 
contraction  is  an  indication  of  rapid  decline,  and  is  accom- 
panied by  oedema  or  other  trophic  disturbance. 

It  would  be  hardly  necessary  to  refer  here  to  the  opinion 
of  Austin — that  the  left  pupil  is  more  frequently  dilated  in 


*  Particularly  if  the  contour  of  the  pupil  is  not  round  but  irregular — 
a  condition  which  must  be  distinguished  from  the  residual  irregularity 
following  syphilitic  iritis,  a  not  uncommon  condition  in  paretic  dements. 


208 


INSANITY. 


paretic  dements  having  exuberant  ideas,  and  the  right  in 
those  with  depressive  ideas — if  it  were  not  for  the  fortu- 
nately isolated  attempt  which  a  recent  writer  on  the  disease 
made  to  resuscitate  this  exploded — not  to  say  a  priori  ab- 
surd and  extravagant  view — by  certain  statistics  which 
happen  to  answer  themselves.* 

The  pupil  is  found  to  have  the  characteristic  features 
known  as  the  "  Argyle  Robertson  pupil  "  in  those  cases 
where  the  spinal  symptoms  are  well  marked  and  ataxia  or 
abolished  tendon  reflex  and  other  evidences  of  posterior 
sclerosis  are  early  signs.  This  symptom  is  not  as  frequent 
in  paretic  dementia  as  has  been  claimed  by  some  recent 
writers. 

It  is  not  necessary  to  refer  here  in  detail  to  the  signs  ac- 
companying the  organic  affections  of  the  cord  sometimes 
found  in  paretic  dements,  or  to  the  signs  of  focal  hemi- 
spheral  lesion  which  are  its  frequent  accompaniments.  The 


*  Austin  ("  On  General  Paralysis."  London,  1859)  says:  "When  the 
right  pupil  has  been  the  more  affected  \.\\& general  tone  of  the  delusions  has 
been  more  melancholic,  and  with  a  more  implicated  left  pupil,  their  usual 
complexion  has  been  elated,  and  their  coloring  gorgeous."  (Italics  Aus- 
tin's.) Pelman  and  Nasse  took  the  trouble  to  demonstrate  the  untena- 
bility  of  this  view,  but  no  one  succeeds  better  than  the  writer  referred 
to  in  the  text,  who,  in  thebelief  that  he  is  supporting  Austin,  says:  "  From 
an  examination  of  eighty  cases  in  the  asylum  in  which  there  was  a  per- 
ceptible tendency  in  one  or  the  other  direction,  it  would  appear  as  if 
there  was  something  in  the  theory,  for  in  the  melancholic  cases  the  left 
pupil  was  the  more  dilated  in  thirty  and  the  less  in  only  eight;  while  of 
the  maniacal  the  right  was  the  larger  in  thirty-three,  and  the  left  in  but 
nine."  ("General  Paresis,"  by  A.  E.  Macdonald,  M.D.,  ^4;;/.  y^//;- .^t/" 
Insanity,  April,  1S77.)  A  comparison  of  the  respective  statistics  furnishes 
the  most  sinister  disproval  which  any  theory  has  ever  experienced,  and 
also  constitutes  a  significant  commentary  on  the  reliability  of  certain 
pamphlets.     Austin's  figures  are  cited  from  his  table  on  p.  36. 


Number  of  paretics 
with     pronounced 
elation  or  depres- 
sion. 

he'" 

C         u 

'Si!  f 

«■-£? 
•S  c'5. 

g  0  3 
1"" 

41— 

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CTlT    ^ 

•5  c'H. 
s  *.  a. 

rtrS 
■SO. 

c 

1:2 

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Ac 

u.2-2 

4>   M-- 
6  u  3 

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•a  3 
c 

n. 

u  0  «' 
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§0.0. 

Austin's  fig- 
ures  

64 

1 

15 

s 

39                       I 

3 

His  support- 
er's figures. 

80 

33 

9 

-8         1         30 

PARETIC   DEMENTIA.  209 

attempt  to  do  justice  to  these  themes  would  necessitate  the 
extending  this  chapter  to  the  dimensions  of  a  volume. 

Among  the  motor  disturbances  those  of  the  facial  mus- 
cles, the  hands,  and  tongue  are  of  the  greatest  diagnos- 
tic importance;  in  fact,  the  expressions  of  the  paretic's  face, 
like  his  speech,  are  the  most  prominent,  constant,  and  char- 
acteristic physical  indications  of  his  disease. 

The  prodromal  period  is  not  always  marked  by  a  perma- 
nent disturbance  of  the  facial  and  lingual  innervations. 
There  is  less  of  the  normal  play  of  the  features,  or  it  is  ex- 
aggerated owing  to  a  slight  ataxia:  usually  fibrillary  tremors 
accompany  the  more  pronounced  changes  of  expression, 
particularly  when  the  patient  is  excited.*  With  this  the 
explosive  opening  of  spoken  sentences  referred  to  in  the 
earlier  part  of  the  chapter  may  be  occasionally  observed, 
and  it  increases  after  the  various  exacerbations  and  para- 
lytic episodes  of  the  disease,  being  particularly  marked 
with  the  consonants  requiring  labial  apposition  and  lingual 
firmness.  The  patient,  like  an  intoxicated  person,  finds  it 
difficult  or  impossible  to  say  "  truly  rural,"  or  "  Peregrine 
Pickle,"  and  will  instead  say  t-t-t-tooly  roodal — t-t-t-trural 
roo-roo-roodial.  "  Emotional  tremor,"  as  it  is  called,  is  also 
frequently  noted.  The  patient,  when  about  to  speak  or 
when  suddenly  accosted,  is  seen  to  have  a  fine  tremor  of  the 
lips,  particularly  marked  about  the  angles  of  the  mouth,  as 
if  he  were  about  to  break  out  in  sobs.  But  there^  is  no 
real  emotional  state;  the  patietit  may  be  extravagantly  hi- 
larious at  the  time,  and  the  designation  is  a  misnomer,f  for 
this  tremor  is  an  ataxic  associated  movement  and  should 
be  designated  "paretic"  or  "ataxic  tremor." 

As  the  disease  progresses  all  these  symptoms  become  in- 
tensified; a  variable  degree  of  ptosis,  or  drooping  of  the 
upper  eyelid,  is  noted,  and  the  features  generally  are  coarser 
and  finally  become  obliterated  altogether.  A  characteristic 
element  of  the  facial  expression  in  advanced  paretic  de- 
mentia is  a  tonic  contraction   of  the  corrugator  supercilii 

*  The  "  Nachbewegungen"  and  "  Mitbewegungen"  of  the  Germansare 
very  commonly  observed. 

f  There  is  sometimes  observed  very  early  in  the  disease  a  morbid 
pseudo-emotional  condition.  The  patient  experiences  the  expression  of 
emotions  without  a  corresponding  emotional  state ;  reminiscences  of  a 
pleasant  character,  for  example,  are  accompanied  by  choking  sensations 
in  the  throat  and  a  flow  of  tears,  while  those  of  an  opposite  kind  may  be 
associated  with  a  vacant  smile. 


210  INSANITY. 

and  the  occipito  frontalis.  Probably  this  action  is  at  first  a 
sort  of  automatic  equipoise  for  the  paralysis  of  the  levator 
palpebrae,  and  then  becomes  habitual;  for  it  is  most  marked  in 
those  cases  where  the  ptosis  is  extreme,  and  on  that  side  of  the 
face  where  the  latter  is  most  pronounced.  The  fine  tremor  of 
the  lips  becomes  coarser,  and  fibrillary  twitches  of  thezygo- 
matici,  the  levator  labii  superioris,  and  particularly  of  the 
muscles  of  the  tongue,  which  may  have  been  only  occasional 
occurrences  in  the  earlier  periods,  now  become  constant.  A 
pronounced  coarse  tremor  is  observed  in  the  hand  on  or- 
dering the  patient  to  stretch  it  out  while  spreading  the 
fingers;  and  the  handwriting,  which  shows  at  first  only  a 
similar  tremor,  degenerates  to  scrawling,  and  the  deviations 
from  straight  lines  are  more  considerable.  The  patient  fre- 
quently erases  or  blots  his  words,  and  a  most  constant  feat- 
ure is  a  gradual  deterioration  of  the  handwriting  in  lengthy 
documents;  the  patient  begins  a  letter  very  fairly,  but,  as  he 
goes  on,  the  words  are  formed  more  irregularly,  and  finally 
he  is  unable  to  keep  on  the  line,  writes  above  or  below 
it,  but  usually  runs  obliquely  down  across  the  page.  While 
the  opening  of  the  letter  may  be,  aside  from  the  tremor, 
written  in  a  good  business  hand,  the  signature  may  be  illeg- 
ible, a  mere  scrawl,  or  a  blot.  The  omission  of  words,  the 
meaningless  repetition  of  whole  sentences,  the  doubling  of 
single  and  the  reduction  of  double  consonants  are  among 
the  features  of  more  strictly  psychical  origin  which  serve 
to  characterize  the  documents  of  paretic  dements.  Of  these 
such  patients  usually  carry  a  quantity  in  their  pockets,  and 
many  of  them  exhibit  a  stupid  letter-writing  tendency 
which  in  less  educated  ones  is  replaced  by  as  empty  a  word 
diarrhoea. 

The  other  co-ordinated  movements  of  the  hands  suffer 
with  the  writing.  The  patient  who,  if  a  mechanic,  first  no- 
ticed an  inability  to  carry  out  his  finer  manual  work,  now 
becomes  unable  to  button  his  clothes,  or,  in  extreme  cases, 
to  carry  a  spoon  to  his  mouth  without  spilling  its  contents. 

In  the  lower  extremities  the  motor  disorder  manifests  it- 
self, as  a  rule,  in  a  combination  of  paraparesis  and  ataxia, 
whose  characters  will  vary  according  as  the  lesion  of  the 
cord  or  that  of  the  brain  preponderates;  for  symptoms  hav- 
ing a  superficial  resemblance  may  be  due  to  lesions  in 
either  localit}^  contrary  to  the  general  belief. 

It  is  exceptional  to  find  typical  locomotor  ataxia  in  pa- 
retic dementia;  there  is  usually  less  of  the  throwing  out  of 


PARETIC   DEMENTIA.  211 

the  leg  and  bringing  down  of  the  heel,  and  much  less  sway- 
ing on  the  patient  shutting  his  eyes,*  and  equally  less  un- 
certainty on  walking  in  the  dark.  In  advanced  cases  the 
legs  are  dragged  along  the  floor,  often  unequally  so,  giving 
the  impression  of  a  halt  or  limp,  the  chief  movement  of  the 
extremity  is  at  the  hip  joint,  the  knees  being  stiff  and  the 
patient  consequently  sways  to  and  fro  in  walking.  Finally 
— scarcely  able  to  lift  his  leg  from  the  ground,  stumbling  over 
his  feet — while  announcing  the  project  to  walk  around  the 
world  in  twenty  days,  or  "  to  take  the  belt  from  Rowell," 
the  patient  is  compelled  to  take  to  his  bed.  It  is  remark- 
able how,  in  testing  the  resisting  power  of  the  muscles  when 
the  patient  is  in  bed,  these  may  be  found  quite  powerful, 
albeit  the  patient  is  unable  to  walk.  This  discrepancy  is 
to  be  explained  on  different  grounds  from  that  observed  in 
locomotor  ataxia. 

A  very  important  motor  disturbance  in  paretic  dementia 
is  that  of  the  muscles  of  deglutition  and  phonation.  How 
much  of  this  is  really  an  ataxic  disorder  the  writer  is  un- 
able to  determine;  though  it  is  to  be  supposed,  in  view  of 
the  anaesthesia  of  the  larynx  and  pharynx  observed  in  sev- 
eral cases,  that  a  sensory  disturbance  may  enter  as  an  ele- 
ment into  the  dysphagia  so  frequently  noted.  The  patient 
is  very  often  suffocated  by  a  bolus  of  food,  and  more  than 
once  has  the  tube  of  the  stomach-pump  been  passed  into 
the  larynx  and  trachea  without  any  of  the  usual  indications 
of  this  accident  on  the  part  of  the  patient. 

It  is  difficult  to  determine  the  precise  extent  and  charac- 
ter of  the  numerous  sensory  disorders  in  paretic  dementia, 
owing  to  the  inattention  and  dementia  of  the  patients. 
These  signs  will  therefore  never  have  the  diagnostic  impor- 
tance which  the  other  symptoms  have,  and  we  may  there- 
fore pass  by  them  with  this  reference. 

Disturbances  of  the  bladder  and  the  renal  excretion  are 
frequently  observed  in  paretic  dements.  Aside  from  the 
episodial  albuminuria,  reported  by  various  observers  as 
a  sequel  of  the  apoplectiform  attacks,  and  such  rare 
phenomena  as  haematuria  (noted  in  one  case  within  the 
writer's  experience),  cystitis,  and  pyo- nephritis  are  common 
occurrences  toward  the  close  of  the  disease,  and  often  end 
the  patient's  life.     The  more  marked  the  spinal  lesion   the 

*  Commonly  there  is  a  decided  unsteadiness  in  standing  with  the  eyes- 
open,  which  is  not  greatly  increased  by  closing  them. 


212  INSANITY. 

earlier  will  paresis  of  the  bladder  and  its  attendant  phe- 
nomena appear.  There  are  cases,  however,  in  which  the 
urinary  secretion  does  not  present  any  anomalies  whatever, 
nearly  to  the  last  moment,  and  then  they  may  be  the  distant 
result  of  over-distension  of  the  bladder  through  the  amnesic 
neglect  of  the  patient. 

The  Vaso-motor  and  trophic  disturbances  of  paretic 
DEMENTIA  are  among  the  most  interesting  and  striking 
symptoms  of  its  later  stages.  Early  disturbances  of  a  vaso- 
motor nature  are  the  flushings  of  the  head  after  meals,  and 
the  similar  spells  which  herald  the  apoplectiform  and 
epileptiform  attacks  already  desci'ibed.*  Anomalies  of  the 
body  temperature  have  also  been  claimed  to  exist  at  vari- 
ous periods,  but  the  evidence  on  this  point  is  still  ver}?^  con- 
tradictory, and  the  writer's  own  observations,  made  some 
years  ago  in  conjunction  with  Dr.  Kiernan,  were  not  suffi- 
ciently systematized  to  be  of  value  except  with  regard  to 
two  points  :  In  the  first  place,  those  patients  who,  compar- 
atively bright  and  active  in  the  morning,  deteriorated 
through  the  day,  becoming  listless,  stupid,  and  having  to 
be  taken  to  bed  in  the  afternoon,  were  found  to  have  no  rise 
in  temperature,  and  in  a  few  cases  a  fall  of  nearly  a  "degree 
(Fahrenheit)  toward  evening.  In  the  second  place,  a 
rise  in  temperature  amounting  to  between  one  and  five 
degrees, f  more  marked  in  severe  than  in  mild  cases,  was 
noted  to  occur  after  the  apoplectiform  attacks,  and  to  grad- 
ually decrease  with  recovery  or  death.  On  the  whole,  how- 
ever, and  particularly  in  the  earlier  periods  of  the  disease, 
the  revelations  of  the  thermometer  are  not  constant  nor 
pathognomonic. 

The  PULSE  in  the  early  stages  reveals  very  high  tension  in 
the  active  forms  of  the  disease;  in  a  large  number  of  patients 
it  is  normal,  and  in  the  depressive  forms  the  writer  has  found 
unusually  low  tension  in  several  cases.  The  "plateau"  at 
the  summit,  claimed  by  Voisin  even  for  the  early  period,  is 
found  only  in  these  cases  and  toward  the  end  of  the  dis- 
ease, when  there  is  marked  cardiac  enfeeblement;  it  then 
does  not  differ  from  the  flattening  of  the  percussion  apex 
found  in  other  forms  of  dementia.     The  revelations  of  the 

*In  the  prodromal  period  of  the  disease  the  writer  has  found  remark- 
able and  undoubtedly  pathological  variations  of  the  surface  temperati/7-e 
particularly  of  the  hands  and  forehead,  it  being  very  high  after  meals  and 
rhental  strain. 

f  Fatal  termination. 


PARETIC   DEMENTIA.  213 

sphygmograph,  like  those  of  the  thermometer  in  paretic 
dementia  are  of  high  scientific  but  not  of  any  great  diag- 
nostic value,  except  indirectly  in  this  way:  there  is  often — 
and  in  advanced  cases  constantly — found  an  irregular  and 
coarsely  wavy  character  of  the  line  of  descent,  which  is  the 
expression  of  the  irregular  muscular  tremor  of  this  disease. 

Among  the  more  important  vaso-motor  disorders  are  the 
changes  in  the  bones,  gangrene  of  the  lung,  and  the  malig- 
nant bed-sore.  The  former,*  like  the  othaematomata  some- 
times found  in  advanced  paretic  dementia,  have  been 
referred  to  in  Chapter  X. 

The  gangrene  of  the  lungs  found  in  paretic  dementia 
may  be  due  to  septic  absorption  from  bed-sores,  to  the 
passing  of  food  into  the  trachea  and  bronchi,  and,  finally,  it 
may  result  from  central  processes,  developing  in  numerous 
foci  with  the  apoplectiform  attacks,  and  probably  in  a  man- 
ner analogous  to  the  multilocular  pulmonary  lesions  found 
after  ordinar}''  cerebral  hemorrhage. 

Decubitus  is  common  in  paretic  dements  who  are  bed- 
ridden; but  there  is  a  kind  of  bed-sore  which  is  not  due  to 
pressure  or  to  maceration  by  urine  like  the  ordinary  variety, 
and  which  develops  particularly  after  the  apoplectiform 
attacks.  It  begins  as  an  erythematous  spot  of  a  purplish 
color,  on  which  vesicles  appear,  after  whose  bursting  the 
livid  surface  of  a  deep  tissue  infiltration  becomes  visible. 
This  latter  rapidly  undergoes  necrosis,  and  the  destructive 
process  may  extend  so  deep  as  to  involve  the  sacrum  and 
reach  the  spinal  canal. f  This  is  one  of  the  most  furibund  of 
the  complications  of  paretic  dementia;  ar\d\\i&  malig/iajit bed- 
sore, as  it  is  properly  called,  may  develop  in  a  few  days  and 


*  In  paretic  dementia  with  pronounced  posterior  sclerosis  the  joint  and 
bone  chantj^es  found  with  that  disease  may  be  observed. 

f  At  the  thirty-eighth  meeting  of  the  "  Berliner  Psychiatrischer  Verein," 
Dr.  C.  Reinhard  reported  a  case  of  a  female  paretic,  in  whom  numerous 
microparasites  (microsporon  septicum)  were  found  in  the  nerve-centres, 
with  septic  cerebro  spinal  leptomeningitis.  These  lesions  were  due  to 
septic  invasion  by  way  of  the  intervertebral  openings  and  the  cerebro- 
spinal fluid  from  a  decubitus. 

It  is  not  necessary  to  refer  here  in  detail  to  certain  pathological  curi- 
osities, such  as  Addison's  disease  (observed  in  one  case),  mottling  of 
the  skin,  exophthalmus  (in  one  dispensary  and  in  one  asylum  patient), 
pemphigus,  purpura,  unilateral  sweats,  spontaneous  gangrene,  hae- 
morrhage in  the  stomach,  rhinhsematoma  and  haematoma  of  the  lower 
bowel,  which,  with  other  trophic  disturbances  too  numerous  to  mention, 
are  occasionally  found,  though  not  characteristic  of  the  disease. 


214  INSANITY. 

run  a  fatal  course  in  a  week.  Sometimes  several  of  these 
sores  appear  simultaneously  in  large  numbers,  at  the  troch- 
anters, heels,  occiput,  and  elbows;  and  their  rapid  develop- 
ment, the  absence  of  the  ordinary  causes,  and  the  fact  that 
they  chiefly  appear  after  the  apoplectiform  attacks,  justify 
us  in  considering  them  to  be  of  trophic  origin. 

Varieties  of  Paretic  Dementia. — Most  modern  authors 
make  a  number  of  subdivisions  of  this  disease.  Some  years 
ago  the  writer*  differentiated  from  the  typical  variety,  in 
which  the  prodromal  symptoms  are  mental  and  are  followed 
by  disturbances  of  the  eyeball,  face,  tongue,  and  pharynx 
movements,  and  which  appears  to  be  a  "  descending"  affec- 
tion, that  form  in  which  the  mental  symptoms  appear 
after  serious  evidences  of  a  spinal  or  axial  affection  of  the 
nervous  system  have  been  observed,  and  which  may  be 
classed  as  an  ascending  affection. f  There  is  no  necessity 
for  making  any  further  subdivisions.  Some  cases,  as  al- 
read}'^  mentioned,  run  a  "galloping"  course,  others  are 
evenly  progressive  (the  so-called  quiet  cases),  and  most 
are  marked  by  remissions. 

The  remissions  of  paretic  dementia  merit  our  special  at- 
tention. Countless  have  been  the  errors  made  by  those 
who  have  looked  on  these  hiati  in  the  disease  as  recoveries. 
There  is  no  more  remarkable  and  deceptive  observation  in 
neuropathology  than  the  abatement  of  a  dementia  with 
delusions  of  grandeur,  which  permits  the  patient  to  return 
to  his  vocation,  and  the  simultaneous  disappearance  of  a 
paralysis  and  ataxia,  whicli  may  have  been  complicated  by 
episodes  of  an  almost  fatal  character.  Although  residua 
of  the  symptoms  may  mark  the  period  of  remission,  yet 
there  are  exceptional  cases  where  even  the  expert  may  be 


*  Psychological  Pathology  of  Progressive  Paresis,  Journal  of  Nervous 
and  Mental  Diseases,  1877. 

f  At  the  time  the  writer  was  unable  to  separate  a  series  of  cases,  in 
which  there  was  a  quiet  progressive  dementia,  with  progressive  paresis, 
ataxia,  and  epileptiform  episodes,  from  typical  paretic  dementia,  although 
aware  that  the  lesion  which  produced  this  combination  was  a  peculiarly 
distributed  multiple  sclerosis.  The  opinion  of  authorities  generally  is  to 
the  effect  that  these  cases,  like  certain  clinically  similar  ones  of  cerebral 
syphilis,  should  not  be  included  in  paretic  dementia.  The  question, 
however,  is  still  stib  judice  whether  there  is  not  every  connecting  link 
between  these  various  affections,  and  it  is  greatly  complicated  by  the 
fact  that  undoubted  paretic  dementia  is  found  in  numerous  syphilitic  sub- 
jects on  the  one  hand,  while  there  is  a  special  form  of  syphilitic  mental 
disorder  on  the  other. 


PARETIC   DEMENTIA.  21$ 

unable  to  detect  any  deviation  from  the  standard  of  mental 
and  physical  health.  In  the  vast  majority  of  cases,  however, 
tremor  of  the  hands,  inequality  of  the  pupils — if  it  previously 
existed — and  a  slight  speech  defect  and  clumsy  walk  are 
found  more  or  less  prominent  even  in  the  remissions.  An 
anomaly  of  the  moral  or  mental  character,  or  of  both,  is 
also  quite  common.  The  patient  is  given  to  purposeless 
lying,  is  irritable  and  extravagant;  to  the  expert  the  con- 
tinuing dementia  is  but  imperfectly  masked  by  the  super- 
ficial signs  of  recovery;*  while  to  the  laity  the  occurrence 
of  an  assault,  the  expenditure  of  a  fortune,  or  an  apoplecti- 
form attack,  may  prove  tragical  or  costly  comments  on 
their  ready  credulity. 

Oddities  of  behavior  not  previously  noted  in  the  patient 
may  characterize  the  remission.  One  of  the  writer's  patients 
would  stop  before  every  looking-glass,  manipulating  his 
side-whiskers  whenever  he  thought  he  was  not  observed. 
Another  became  an  active  politician  and  controversialist, 
although  in  his  sane  period  he  had  a  great  contempt  for 
the  political  career  and  the  general  complexion  of  politics. 

These  remissions  may  last  from  weeks  to  years;  their 
average  duration  is  from  two  to  four  months.  Lionet  and 
Taliet  agree  in  believing  that  they  are  more  perfect  in  the 
congestive  variety.  In  one  case  in  the  writer's  observation, 
which  has  since  been  rapidly  running  a  downward  course, 
the  remission  lasted  three  years,  during  which  time  the 
patient  attended  to  extensive  commercial  undertakings 
with  fair  success,  and  took  charge  of  several  assignments. 
Such  remissions  may  be  regarded  as  constituting  a  transi- 
tion to  a  genuine  recovery,  and  are  particularly  frequent 
with  "  alcoholic"  paretics. 

Although  the  prognosis  of  paretic  dementia  is  almost  un- 
qualifiedly bad,  and  most  of  the  cases  reported  as  recovered 
have  subsequently  relapsed,  yet  there  are  a  few  well-authen- 
ticated instances  where  the  history  of  the  patient  has  been 
traced  for  five  and  six  years  after  his  last  asylum  discharge, 
and  he  has  not  given  the  slightest  indication  of  a  relapse  in 
that  time.  The  writer  met  such  a  patient,  in  whose  case  there 
had  been  a  rheumatic  etiology,  and  who  had  had  a  typical 


*  Morel  aptly  says,  that  when  the  patient,  however  well  he  may  carry 
on  certain  routine  duties,  retains  the  stolid  expression,  the  stony  stare, 
and  the  corrugated  forehead  of  paretic  dementia,  he  is  not  cured,  but 
that  his  disease  is  progressing  under  the  "  mask  of  a  remission." 


2l6  INSANITY. 

outbreak,  five  years  after  his  discharge,  and  was  unable  to 
find  any  indication  of  paretic  dementia  in  him.  A  remark- 
able and  rather  comical  instance  occurred  in  Austria:  a  pare- 
tic dement  escaped ixoxci.  the  asylum,  and  five  years  later  paid 
a  visit  to  the  authorities  to  demonstrate  his  recovery.  Gau- 
ster*  and  Flemmingf  have  also  reported  several  undoubt- 
ed cases  of  recovery;  and,  in  a  case  of  Schule's,J  restitutio 
ad  integrum  even  occurred  after  an  apoplectiform  attack. 

An  observation  is  cited  by  Simon  from  Ferrus  of  a  patient 
recovering  and  remaining  free  from  the  disease  for  twenty- 
five  years,  while  Baillarger,  Bayle,  Calmeil,  and  Sutherland 
report  others  where  the  patients'  histories  were  followed 
up  for  from  six  to  ten  years  after  their  discharge,  and  no 
relapse  occurred.  Baillarger  himself  questioned  whether 
these  were  genuine  cases  of  paretic  dementia;  and  more 
recent  observers  believe  that  they  were  of  the  syphilitic, 
alcoholic,  or  rheumatic  varieties  in  which  cases  the  prog- 
nosis is  relatively  better. 

The  duration  of  the  disease  as  a  whole  is  variable.  It 
has  been  already  stated  that  the  prodromal  period  may 
last  only  a  few  months,  usually  a  few  years,  and  in  rare 
cases  nearly  a  lifetime.  Dating  from  the  explosion  of  the 
malady  the  lethal  termination  may  occur  in  six  months,, 
more  commonly  in  three  years;  and,  in  not  a  small  number 
of  instances,  in  six  or  ten  or  even  more  years.§ 

Paretic  dementia  usually  develops  in  patients  between 
the  thirtieth  and  fortieth  years;  it  has  been  exceptionally 
observed  in  very  aged  individuals,  and  occurred  in  patients 
over  sixty,  in  five  out  of  three  hundred  and  forty-six  cases 
observed  by  the  writer.  The  youngest  paretic  dement  ob- 
served in  this  series  was  aged  eighteen.  TurnbuU  reports 
a  case  of  this  disease  in  a  boy  of  twelve  ;  ||  it  is,  however, 
rare  before  the  twenty-fifth  year,  and  in  young  subjects 
generally  runs  a  more  rapid  course  than  in  older  ones. 

*  Psychiatrisches  Centralblatt,  Oct.  12,  1876.  f "  Irrenfreund,"  1876. 

X  Allgemeine  Zeitschrift  fuer  PsychiaUie,  xxxi. 

§  There  is  now  (1882)  a  "show  patient,"  frequently  brought  out  before 
visitors  and  reporters  at  the  Ward's  Island  Asylum,  if  a  report  in  a  daily 
paper  is  to  be  credited,  who  had  been  ascertained  by  the  writer  to  have 
for  three  years  prior  to  1877  manifested  the  characteristic  signs  of 
paretic  dementia,  and  who  had  an  epileptiform  attack  in  that  year. 

\  Journal  of  Mental  Science,  1882.  The  father  of  this  patient  died  of 
paretic  dementia  afte7-  his  son.  A  Continental  alienist,  the  reference  to 
whose  paper  the  writer  has  lost,  reports  the  case  of  an  imbecile  infant 
whose  mental  deficiency  was  complicated  by  a  paretic  trouble. 


PARETIC   DEMENTIA.  2X7 

Paretic  dementia  is  much  less  frequent  among  females- 
than  among  males;  the  writer  has  seen  but  one  female 
paretic  among  fifty-eight  instances  of  this  disorder  in 
private  and  dispensary  practice.*  In  various  European 
countries  the  proportion  of  female  to  male  paretic  dements 
is  found  to  fluctuate  considerably.  Schuele  gives  the  highest 
figure,  finding  four  paretic  females  to  ten  paretic  males. 
Most  observers  give  the  proportion  as  being  between  i  :  5, 
and  I  :  8.  Neumann,  an  experienced  Prussian  alienist,  did 
not  see  a  single  case  of  paretic  dementia  in  females,  and 
hence  was  led  to  deny  its  existence  in  that  sex.  The  ob- 
servations of  no  single  alienist  can,  however,  be  taken  as 
gauges  of  the  true  relation  of  the  sexes  to  this  disease. 
The  unusual  experience  of  the  writer,  who  found  but  one 
female  paretic  in  fifty-eight  cases,f  chiefly  observed  in 
private  practice,  is  probably  due  to  the  fact,  that  females 
among  the  wealthier  classes  are  not  exposed  to  the  emo- 
tional strain  and  worry  to  which  females  in  the  lower  walks 
of  life  are  exposed.  With  this  it  is  in  accord  that  paretic 
dementia  is  more  frequent  among  females  who  enter  into' 
competition  with  the  male  sex,  and  among  prostitutes  who- 
like  males  are  given  to  alcoholic  excesses  and  exposed  to 
syphilis.  According  to  an  old  report  of  the  Prussian  statis- 
tical office,  there  were  in  the  year  1878  20  female  and  106 
male  paretic  dements  in  private  asylums  in  France,  while 
at  the  same  time  there  were  454  female  and  826  male  pare- 
tic dements  in  the  public  institutions  of  the  same  country. 
The  proportion  of  females  to  males  in  the  wealthier  classes 
was,  therefore,  as  18  :  100;  in  the  poorer  classes,  as  54  :  100, 
in  the  latter  instance  exceeding  even  the  figures  of  Schuele. 

Paretic  dementia  in  females  runs  a  more  even,  less  ex- 
plosive, and  slower  course  than  in  males.  The  maniacal 
attacks  in  the  former  are  not  as  expansive,  the  delusions  of 
grandeur  not  as  pronounced,  and  neither  the  episodical 
exacerbations  nor  the  remissions  are  as  abrupt  as  in  the 
male  patients.  It  is  the  persistent  physical  signs  and  the 
progressing  dementia  that  chiefly  serve  to  characterize  the 
disease  in  females,  as  these  are  the  same  signs  which  in  the 
"quiet"  male    cases    suffice  to  demonstrate   its   existence, 

*  The  284  remaining  cases  are  excluded,  because  they  were  observed 
in  an  asylum  for  males,  and  the  corresponding  statistics  of  the  asylum 
for  females  were  unreliable. 

f  And  a  single  case  during  a  visit  to  the  Bloomingdale  Asylum,  where 
there  were  nineteen  cases  of  the  disease  among  males  at  the  time. 


2l8  INSANITY. 

even  when  delusions,  hallucinations,  morbid  projects,  and 
other  perversions  are  absent.  It  is  dementia,  motor  paraly- 
sis, and  incoordination  of  the  character  described  that  are 
the  necessary  clinical  expressions  of  the  progressive  brain 
wasting  resulting  from  the  morbid  processes  to  be  con- 
sidered in  the  following  chapter. 


CHAPTER  XIII. 
The  Morbid  Anatomy  and  Nature  of  Paretic  Dementia. 

The  organs  of  those  dying  with  paretic  dementia  ex- 
amined by  pathologists  are  usually  obtained  from  subjects 
who  have  reached  the  last  stages  of  that  affection.  The 
brain  and  spinal  cord,  in  such  cases,  show  the  results  of  a 
long-continued  and  often  intense  degenerative  process, 
which  not  a  few  authorities  have  regarded  as  of  an  inflam- 
matory character;  and,  in  the  sense  in  which  the  term 
"inflammation"  is  applied  to  the  chronic  interstitial 
changes  dependent  on  an  altered  blood-supply  in  other 
organs,  such  as  the  liver  and  kidneys,  the  analogous 
changes  in  the  paretic  dement's  brain  may  properly  be 
considered  to  be  the  results  of  a  similar  inflammatory  proc- 
ess of  a  low  grade. 

The  brain  itself  is  found  to  be  wasted;  the  wasting, 
however,  is  not  generally  even  as  in  simple  dementia, 
being  usually  more  marked  in  some  and  less  marked  in 
other  districts.  Thus  the  convolutions  near  the  base  of 
the  brain  may  be  full,  and  show  the  normal  contours, 
while  those  of  the  paracentral  lobule,  of  the  infra-parietal 
lobule,  or  of  the  entire  convexity  of  the  frontal  lobe,  may 
be  atrophied,  and  separated  by  widely  gaping  sulci. 
Usually  the  basilar  parts  show  no  gross  wasting;  in  two 
out  of  fifteen  subjects  examined  by  the  writer  there  was 
marked  reduction  in  the  depth  (dorso-ventral  diameter)  of 
the  pons,  which  on  a  closer  examination  was  found  to  be 
due  to  the  wasting  of  the  transverse  fasciculi  of  that 
segment;  in  a  third  case  there  was  a  general  diminution  in 
all  dimensions  of  the  medulla  oblongata  as  well  as  of  other 
portions  of  the  isthmus.  This  exceptional  observation  is 
of  but  little  value,  however,  as  the  patient  was  over  seventy 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   219 

years  of  age.  At  this  period  of  life  wasting  of  the  axial 
parts  of  the  nervous  system  is  not  uncommon. 

The  characteristic  feature  of  the  structural  cortical 
changes  in  paretic  dementia  is  (in  harmony  with  the  gross 
appearances)  the  fact  that  they  are  rarely  general,  but  that 
they  affect  certain  cortical  provinces  more  than  others,  and 
leave  some  of  them  nearly  or  entirely  intact.  Usually  the 
cortex  is  discolored,  sometimes  being  preternaturally  pale, 
at  others  presenting  a  marked  rosy  tint,  due  to  an  injec- 
tion of  the  minute  blood-vessels.  In  one  case  a  rusty  color 
was  noted  in  several  spots  of  the  deep  cortical  layers,  ex- 
tending deeply  into  the  white  substance,  in  large  and 
occasionally  confluent  patches.  The  consistency  varies  in 
two  ways:  in  some  cases  the  cortex  is  less  firm  than  nor- 
mal— without,  however,  reaching  the  degree  of  a  necrotic 
softening,  as  some  have  claimed, — in  others  it  is  firmer  than 
normal,  and  in  a  few  the  induration  approaches  the  degree 
of  sclerosis.  Occasionally  these  different  conditions  are 
associated  in  the  same  case,  different  parts  of  the  brain 
being  differently  affected.  The  writer  has  found  that  com- 
monly the  white  substance  immediately  subjacent  to  the 
cortex  is  firmer  than  the  cortex  itself,  having  frequently  a 
faint  bluish  or  grayish  tinge.  As  the  pia  is  more  intimately 
adherent  to  the  cerebral  surface  than  in  health  the  result 
is,  that  in  some  examinations,  on  removing  the  membranes, 
the  entire  cortex  follows  the  latter,  separating  at  the  point 
where  the  softest  gray  tissues  adjoin  the  firmest  white 
layer,  and  thus  leaving  the  white  substance  behind  in  a 
shape  repeating  all  the  anfractuosities  of  the  surface.* 

A  very  frequent  appearance,  in  advanced  paretic  demen- 
tia, is  cystic  degeneration  of  the  cortex.  The  gray  and  some- 
times both  the  gray  and  white  substances  of  some  one 
or  other  area  are  found  to  be  the  seat  of  numerous  cav- 
ities, varying  in  size  from  a  pin's  point  to  a  millet  seed. 
When  these  are  very  closely  crowded  the  so-called  gruytre 
cheese  appearance,  described  by  Lockhart  Clarke,  results. 
(Fig.  2f.)      In   several   cases    the  writer  has   found   these 


*  Baillarger  (Note  sur  une  Alteration  du  Cerveau  Caracterisee  par  la 
Separation  de  la  Substance  Grise  et  de  la  Substance  Blanche  des  Cir- 
convolutions.  Annates  Mddico-Psychologiques,  January,  1882)  first  accur- 
ately described  this  lesion. 

f  Two  convolutions  from  the  mesal  face  of  the  right  cerebral  hemi- 
sphere of  an  aged  paretic  dement.     The  cavities  in  this  case  opened  on 


220 


INSANITY. 


cavities  to  be  branched  ;  in  one  the  sclerotic  stem  of  an 
obliterated  blood-vessel  protruded  into  it;  and  from  these 
and  a  number  of  other  observations  there  can  be  no  doubt 
that  the  larger  cavities  at  least  are  of  perivascular  origin, 
and  the  result  of  a  retardation  of  the  lymph  out-flow,  with 
a  consequent  dilatation  of  the  spaces  of  His  and  Robin.  It 
is  possible  that  the  smaller  cavities  are  the  result  of  an 
analogous  expansion  of  the  periganglionic  (pericellular) 
spaces.  The  view  that  all  these  gaps  are  analogous  in 
their  origin  to  retention  cysts,  is  supported  by  the  fact 
that  sclerosis,  thickening,  infiltration,  and  adhesion  of  the 
pia,  all  factors  which  are  apt  to  prove  obstructive  to  the 
iymph  out-flow,  if  not  to  the  venous  return  circulation,  are 


Fig.  2. 


Fig.  3,f 


found  most  marked  over  those  areas  exhibiting  cystic 
degeneration.  Probably  the  dilatations  of  the  lymph  space 
in  the  posterior  fissure  of  the  spinal  cord  (Fig.  7),  found  in 
one  case  by  the  writer,  are  susceptible  of  a  similar  inter- 
pretation. 

The  ventricles  may  be  enlarged  in  advanced  cases;  often 
they  exhibit  no  change  in  dimensions,  and  a  more  charac- 
teristic pathological  feature  of  the  disease  is  the  granular 
change  of  their  endyma  or  lining  membrane.*     This  con- 


the  surface,  which  is  rare;  h,  the  cortical  surface;  c  w,  cross  section;  c 
being  the  cortical,  and  iu  the  medullary  portion  of  the  section. 

*  Wilder  suggests  this  term  as  preferable  to  ependyma,  which  latter 
term  may  be  restricted  to  the  barren  layer  of  the  cortex  to  which  Roki- 
tansky  applied  it. 

f  Dorsal   view   of    medulla   oblongata:    0,    striae   acustici;     c,    coarse 
granulations  near    the  apex  and    over  the    alae  cin/rese    (nuclei  of   the    6/ 
glossopharyngeal  and   pneumogastric  nerves);   a,    finer  granulations  ap- 
proaching those  producing  the  ground/glass  appearance.     -7 


THE    MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   221 

sists  in  a  connective  tissue  growth  of  the  ventricular  lining, 
which  takes  place  in  numerous  and  closely-crowded  areas, 
raising  the  latter  in  little  hillocks.  As  long  as  these  re- 
main minute  they  manifest  their  presence  to  the  naked 
eye  by  the  dulness  of  the  normally  smooth  and  polished 
lining  of  the  ventricle;  in  other  words,  by  a  ground-glass  ap- 
pearance. When  they  increase  they  assume  the  shape  of 
warty  excrescences,  and  these  are  found  particularly  well 
marked  in  the  posterior  half  of  the  fourth  ventricle  (Fig.  3), 
at  the  foramen  of  Monro  and  over  the  striae  cornese.  Quite 
odd  forms  are  sometimes  seen  among  these  bodies.  Of  the 
larger  ones,  which  usually  have  a  constricted  pedicle  (Fig. 
5),  two  occasionally  join  leaving  a  tunnel  between  them. 
In  one  case  the  writer  found  the  aqueduct  of  Sylvius  divided 
into  two  channels  by  a  series  of  them. 

The  ganglionic  bodies  of  the  cortex  generally  exhibit 
marked  degeneration.  But,  side  by  side  with  areas  in 
which  it  is  difficult  to  find  a  single  healthy  ganglionic  ele- 
ment of  fair  dimensions,  there  may  be  found  regions  in 
which  no  change,  or  but  very  slight  changes,  can  be  found; 
and  in  one  recent  case  the  writer  was  unable  to  find  any 
pathological  condition  in  these  elements,  although  sections 
from  every  district  of  the  cerebral  surface  were  carefully  ex- 
amined. Mendel  found  that  the  changes  in  the  ganglionic 
bodies  are  not  always  evenly  developed  with  the  ordinary 
signs  of  that  interstitial  encephalitis,  which  is  ordinarily 
supposed  to  characterize  the  affection.  In  three  cases  in 
which  he  failed  to  find  any  indications  of  this  process 
he  found  the  peri-ganglionic  spaces  filled  with  yellowish 
fliocculi,  the  nuclei  of  the  ganglionic  bodies  being  indistinct 
or  invisible,  with  other  indications  of  necrobiosis.*  The 
writer  has  found  the  following  varieties  of  degeneration  in 
the  cortical  elements:  ist.  An  even  shrinking  of  the  pyra- 
midal bodies,  without  protoplasmic  deterioration;  the  pro- 
toplasm is  merely  condensed,  and  the  bodies  stain  more 
deeply  than  normal  ones,  while  their  processes  are  fragile. 
2d.  A  diffuse  yellowish  discoloration  of  the  entire  gangli- 
onic body,  extending  into  its  processes,  with  a  disappear- 
ance of  the  finely  granular  structure  of  the  protoplasm;  the 
body  appears  hyaline,  does  not  take  carmine  staining,  and 
its  processes  cannot  be  traced  any  considerable  distance, 

*  Report  of  the  meeting  of  the  Berlin  Medical  Society  of  February 
14th,  1883.     Deutsche  Medizinal-Zeitung,  iv.  8. 


222 


INSANITY. 


the  nucleus  may  stain  faintly,  or  not  at  all,  but  is  usually 
visible.  3d.  A  coarse  pigmentary  change;  a  part  of  or 
the  entire  cell  is  filled  with  coarse  granules  of  a  brownish 
or  yellowish  green,  and  rarely  of  a  decidedly  black  color;  the 
pyramidal  cells  usually  maintain  their  contour  and  exhibit 
the  origin  of  their  processes,  but  the  prolongations  of  the 
latter  are  destroyed,  and  the  nucleus  is  rarely  visible  in  ex- 
treme degrees  of  this  change.  4th.  A  "  granular  wast- 
ing" at  the  periphery  of  the  ganglionic  body,  leaving  a  part 
of  the  latter  apparently  intact;  usually  a  large  number  of 
free  bodies  are  found  in  the  periganglionic  spaces  in  this 
condition,  and  it  seems  that  their  presence  is  in  some  way 

Fig.  4.* 


associated  with  this  change.  5th.  A  progressive  deteriora- 
tion in  the  protoplasmic  composition;  the  ganglionic  body 
is  found  to  have  its  normal  outline,  but  does  not  stain  at 
all,  or  very  imperfectly,  the  nucleus  is  shrunken,  and  the 
nerve  processes  appear  to  have  broken  off  sharply.  This  is 
probably  a  sclerotic  condition.  All  these  changes  are  bet- 
ter marked  in  the  larger  elements,  with  the  exception  of  the 


*  Section  from  the  white  substance,  adjoining  the  gray  matter  of  the 
lower  frontal  convolution,  and  showing  four  large  and  several  small 
spider-shaped  cells.  At  y  one  of  these  cells  has  contracted  a  union  with 
a  small  capillary,  and  one  of  its  processes  is  becoming  transformed  into  a 
capillary  process;  at  11  two  coarse  axis  cylinders  are  seen. 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   22$ 

second  variety,  which  is  found  mostly  in  pyramidal  cells 
of  the  second  and  third  layers. 

Beside  the  ganglionic  bodies,  which  show  various  de- 
grees of  the  enumerated  changes,  patches  of  loose  pig- 
ment or  irregular  masses  of  no  decided  histological  charac- 
ters are  found,  marking  the  former  sites  of  destroyed  ones. 

Little  of  the  positive  is  known  about  the  fibres  of  the 
white  substance.  A  striking  appearance  in  advanced  cases 
is  the  distinctness  and  coarseness  of  the  axis  cylinder,  which 
often  appears  as  if  dusted  over  with  a  fine  powder.  The 
course  of  the  fibres  in  the  white  substance  is  much  more 
clearly  demonstrable  in  the  brains  of  paretic  dements  than 
in  those  of  healthy  persons,  owing  to  the  condition  alluded 
to,  which  is  probably  only  a  preliminary  step  to  the  dis- 
integration of  the  fibre. 

Disease  of  the  neuroglia  is  almost  constant  in  paretic 
dementia.  It  may  be  of  every  degree  and  present  every 
connecting  link  between  a  general  indurating  and  rarefying 
change  of  slight  intensity,  and  the  process  known  as  dis- 
seminated sclerosis.  A  common  feature  is  the  presence  of 
cells,  staining  deeply  in  carmine  and  provided  with  numer- 
ous brush-like  processes:  the  spider-shaped  cells  of  Meynert 
and  Lubimoff.  (Fig.  4.)  These  bodies  are  often  found  in 
large  numbers,  and  the  writer  has  never  failed  to  discover 
them  in  advanced  cases.  In  the  shape  and  size  in  which 
they  are  found  in  paretic  dementia  they  can  be  confounded 
with  no  normal  structure,  as  some  writers  have  suspected 
to  be  the  case.  The  basis  substance  of  the  neuroglia  ex- 
hibits the  degenerative  changes  enumerated  on  page  105, 
and  in  addition  considerable  nuclear  prolifieration. 

The  most  intense,  certainly  the  most  constant,  changes 
of  the  neuroglia  are  found  in  the  pons  and  medulla  oblon- 
gata. Even  in  cases  where  the  spinal  cord  is  not  involved, 
and  where  the  cortex  exhibits  only  a  diffuse  change  of  the 
kind  just  described,  changes  in  color,  consistency,  and  tex- 
ture are  found  in  these  parts.  Sections  taken  from  them 
generally  stain  diffusely  in  carmine  ;  a  coarse  molecular 
material  scattered  between  the  fibres,  along  the  septa,  and 
the  raphe  is  found  to  absorb  the  staining  fluid  in  a  higher 
degree  than  the  ganglionic  elements,*  and  in  advanced 
cases  this  material  becomes  the  seat  of  a  truesclerotic  fibrous 
transformation.     (Fig.  5.) 

*  In  properly  hardened  preparations  these  should  always  stain  earliest 
and  most  intensely. 


224  INSANITY. 

Special  attention  has  been  given  by  observers  to  the 
changes  of  the  blood-vessels.  Nearly  everything  said  w^ith 
regard  to  the  changes  of  the  vascular  channels  on  page  to6 
applies  to  their  condition  in  paretic  dementia.  In  the  earliest 
stages  nuclear  proliferation  of  the  walls  is  observed;  this 

Fig.  5.* 


is  particularly  noticeable  in  the  muscular  coat  of  the  arteri- 
oles and  in  the  adventitia  of  the  smaller  vessels.  In  the 
former  case  the  proliferated  cells  can  be  readily  distin- 
guished from  the  normal  nuclei  of  the  muscular  tunic  by 
the  roundish  or  irregular  shape  and  irregular  disposition  of 

*  Fig.  5.  Transverse  section  of  the  oblongata,  at  the  level  of  the 
tenth  pair.  G,  endymal  granulations  of  the  gray  and  white  fioor  (the 
alae  albae  have  lost  their  white  color,  through  the  connective  tissue 
hypertrophy);  R,  sclerotic  patch  in  the  raphe;  H,  same  around  the  roots 
of  the  twelfth  pair;  J',  same  at  the  ascending  root  of  the  fifth  pair  where 
crossed  by  the  tenth;  B,  same  around  vascular  gap;  F,  "  ponticulus." 
The  left  pyramid  is  darker  than  the  right. 


THE   MORBID   AXATOMY   OF   PARETIC   DEMENTIA.   22$ 

the  former.  In  addition,  the  spots  where  there  is  the  great- 
est amount  of  nuclear  proliferation  (usually  at  the  bifurca- 
tions of,  or  sudden  bends  in,  the  vessels)  are  also  marked  by 
the  presence  of  granular  haematoidin  and  other  products 
of  the  retrogressive  metamorphosis  of  blood  pigment. 
Formed  elements  of  the  blood,  both  red  and  white  corpus- 
cles, are  always  found  in  the  adventitial  space  and  beyond 
it,  usually  in  very  large  numbers;  a  very  characteristic  pic- 
ture of  the  microscopic  sections  of  the  cortex  in  paretic 
dementia  is  the  presence  of  a  series  of  "  nuclear"  bodies 
along  the  borders  of  the  perivascular  space,  many  of  which 
appear  to  be  undergoing  a  transformation  into  spider- 
shaped  cells  (Fig.  4).  With  this  there  is  apt  to  be  found 
an  accumulation  of  similar  bodies  in  the  periganglionic 
spaces. 

An  amorphous  yellowish  substance  is  sometimes  noted 
in  the  adventitial  space,  and  appears  to  be  taken  up  by  the 
neuroglia  nuclei  in  some  instances.*  As  a  rule  the  latter 
lie  in  clear  roundish  spaces,  which  may  contain  a  little 
coarsely-granular  material. 

In  later  stages  of  the  disease  the  nuclear  proliferation 
increases,  and  the  "free  bodies"  undergo  a  transformation 
into  branched  cells  whose  processes  are  connected  with  the 
adventitia  on  the  one  hand,  and  with  the  neuroglia  sur- 
rounding the  vessel  on  the  other.  When  a  blood-vessel  in 
this  condition  is  isolated  from  the  cerebral  substance  it 
presents  a  villous  appearance,  due  to  the  fine  processes  of 
the  branched  cells  attached  to  it.  This  change  is  most 
noticeable  in  blood-vessels  of  moderate  dimensions,  and  not 
well  marked  in  the  capillaries.  The  latter  are  sometimes 
observed  to  establish  a  communication  with  a  process  of 
some  large  spider-shaped  cell,  which  subsequently  becomes 
hollow,  thus  leading  to  the  formation  of  a  new  vascular 
channel. f 

Still  later  the  infiltration  of  the  adventitia  and  muscularis 
with  new  elements  becomes  less  marked  than  the  passive 
phenomena  of  degeneration.     The  muscular  tunic  becomes 

*This  appearance  has  been  observed  not  only  in  specimens  hardened 
in  chromic  acid  or  its  salts,  but  also  in  alcoholic  and  fresh  preparations. 
It  is  found  in  other  conditions. 

f  If  any  analogous  process  occurs  in  the  healthy  state  it  does  not 
occur  in  the  same  prominent  manner,  and  certainly  not  as  extensively  as 
in  paretic  dementia.  The  new  formation  in  question  was  first  described 
by  Lubimoff  and  confirmed  by  the  writer  in  1877. 


226 


INSANITY, 


granular,  its  nuclei  decrease  in  number  and  distinctness, 
and  the  adventitia  either  exhibits  sclerotic  meshes  or  wast- 
ing. The  resisting  power  of  the  vessels  is  evidently  de- 
creased and  fusiform  dilatations  are  common.  Sometimes 
extravasation  of  blood  into  the  adventitial  space  occurs, 
but,  on  the  whole,  this  accident  is  rarer  than  is  ordinarily 
claimed.  Very  frequently  the  vessels  are  kinked  and  con- 
torted, doubled  on  themselves  and  almost  thrown  into  coils 
by  the  excessive  strain  on  their  weakened  walls  (page  107); 

Fig.  6.* 


and  while  Sankey,  who  first  called  special  attention  to  this 
condition,  undoubtedly  employed  methods  which  might 
have  led  to  similar  and  therefore  false  appearances  in  the 
healthy  brain,  and  erroneously  believed  the  adventitial 
sheath  to  be  a  morbid  product,  yet  his  observations  as  to 
vascular  kinking  are  fully  sustained  by  hardened  prepara- 
tions. The  writer  has  found  the  lumen  of  one  vessel  and 
ectasies  of  that  vessel  almost  approaching  in  degree  aneur- 
ismal  dilatations  divided  five  times  by  the  knife  in  a  single 
section. 

A  most  important  field  for  study  in  this  branch  of  morbid 


*Thrombic  cylinder  undergoing  separation  and  checked  at  a  bifurca- 
tion of  a  cortical  capillary. 


THE   MORBID   ANATOMY    OF   PARETIC   DEMENTIA.    22/ 

anatomy  is  the  condition  of  injection  of  the  blood-vessels. 
Usually  these  are  more  or  less  injected,  but  the  most  char- 
acteristic condition  found  is  one  of  thrombic  stasis  (Fig.  6). 
Where  a  patient  had  died  in  consequence  of  a  maniacal 
outbreak,  an  apoplectiform  or  epileptiform  attack,  or  shortly 
after  any  of  these  episodes  of  paretic  dementia  (thirteen 
out  of  fifteen  of  the  cases  examined),  the  writer  always  found 
a  high  degree  of  engorgement  in  the  cerebral  capillaries, 
which  in  places  reached  the  degree  of  a  stasis  more  intense 
than  any  observed  by  the  general  pathologist.  The  blood- 
corpuscles  in  this  state  are  so  closely  crowded  that  their 
outlines  are  no  longer  distinguishable,  and  the}'  appear  fused 
into  a  hyaline  and  opalescent  cylinder  which  stains  deeply 
in  carmine  and  haematoxylin.^'  When  resolution  takes 
place — a  condition  which  is  frequently  observable — this 
cylinder  breaks  up  into  spherical  and  oval  fragments,  which 
are  carried  onward  in  the  vascular  current,  becoming 
further  subdivided  at  each  bifurcation,  and  finally  are 
represented  by  a  number  of  fine  granules  having  each  the 
same  optical  appearance  as  the  larger  masses. f  Thrombic 
stasis  appears  to  be  most  persistent  in  the  white  substance 
subjacent  to  the  cortex  and  the  deepest  layers  of  the  latter. 

Much  discussion  has  grown  out  of  the  claim  that  there  is 
a  new  formation  of  spaces  around  the  cerebral  blood-vessels. 
It  will  be  recollected  that  His  claimed  the  existence  of  an 
extravascular  space  separating  the  blood-vessel  from  the 
surrounding  parenchyma.  In  health  such  a  space  certainly 
does  not  exist,  in  paretic  dementia  it  is  undoubtedlj'  found; 
we  must  therefore  look  upon  it  as  a  morbid  product:  the 
result  of  the  distension  of  the  true  adventitial  lymph  space, 
which,  subsequently  retracting  or  wasting,  leaves  spaces 
behind.  These  are  the  beginnings  of  the  cortical  and 
medullary  cysts  previously  referred  to. 

Before  leaving  the  brain  proper  and  passing  to  the  con- 
sideration of  its  appendages,  it  may  be  stated,  that  the  most 

*This  appearance  has  been  correctly  interpreted  by  Meynert  and 
Lubimoff.  Earlier  observers  have  described  a  similar  appearance  as 
exudations,  fatty  emboli,  etc. 

f  Should  it  be  shown  that  any  of  these  thrombi  on  resolution  pass  the 
cortical  vessels — which,  owing  to  the  tenuity  of  the  latter  (they  being  the 
narrowest  in  the  body),  is  not  likely — it  might  be  possible  to  trace  some 
of  the  multilocular  pulmonary  lesions  observed  after  the  apoplectiform 
attacks  to  emboli  of  the  pulmonary  vessels.  At  present  it  is  safer  to 
attribute  these  lesions  to  trophic  influences,  although  in  some  cases  they 
have  been  shown  to  be  due  to  the  inhalation  of  foreign  bodies. 


^ 


228  INSANITY. 

intense  changes  are — in  a  crude  way — symmetrical.  While 
the  left  cerebral  hemisphere  is  usually  most  involved,  yet 
the  difference  between  the  two  hemispheres  in  respect  to 
the  anatomical  changes  is  not  striking. 

There  is  scarcely  a  ganglion  or  fibre  tract  that  may  not 
be  affected  in  paretic  dementia,  just  as  there  is  scarcely  a 
symptom  studied  by  neurologists  which  may  not  have  been 
observed  during  the  life  of  the  sufferer  from  this  affection. 
The  skull  may  be  thickened  or  the  seat  of  exostoses,  as  in 
other  forms  of  insanity.  In  rare  instances  it  may  be  thinned 
and  softened  in  consequence  of  a  trophic  change.  But  a 
more  characteristic  condition  is  an  intense  injection  of  the 
cranial  diploe,  the  vessels  of  whose  Haversian  canals  are 
filled  to  repletion  in  those  patients  who  reach  the  autopsy 
room  early  in  their  disease.  With  the  nutrition  of  the  skull 
that  of  the  dura  is  also  affected.  As  a  rule  the  periosteal 
or  outer  layer  of  this  membran^e  is  much  more  adherent  to 
the  cranium  than  in  health.  In  one  case  within  the  author's- 
experience  the  adhesion  of  the  dura  at  the  convexity  was 
so  firm  that  a  novice  pathologist  neglecting  to  divide  the 
dura  with  the  bone  (as  should  be  done  in  all  cases  where 
an  unusual  degree  of  adhesion  is  found)  pulled  the  entire 
and  intact  brain  out  of  the  cranial  cavity,  by  tugging  at  the 
calvarium  ;  the  sac  of  the  dura  came  away  almost  entire- 
ly, tearing  off  at  various  points  at  the  base.  Such  and  re- 
lated changes  in  the  dura  are  indications  of  an  over-nutrition, 
as  is  particularly  well  shown  in  the  production  of  genuine 
bony  plates.  Such  plates  are  usually  found  in  the  great 
falx,  and  sometimes  in  the  tentorium.*  They  are  more  fre- 
quently found  in  paretic  dementia  than  in  other  forms  of 
insanity,  with  the  exception  of  the  traumatic  varieties.  A 
typical  specimen  of  the  kind  in  the  author's  possession  is 
about  an  inch  long,  half  an  inch  high,  and  a  third  of  an 
inch  thick;  it  shows  a  median  slit,  into  which  the  falx 
enters,  so  that  it  really  consists  of  two  halves,  each  having 
developed  on  one  side  of  the  falx,  and  the  two  communicat- 
ing through  a  hiatus  in  the  membrane.  These  bodies 
have  the  appearance  and  structure  of  true  bone.  They 
cannot  be  confounded  with  the  calcareous  plates  sometimes 
noted  in  the  arachnoid.     These  are  of  a  creamy  white  color- 

*  They  must  not  be  confounded  with  the  small  spiculae  of  bone  which 
are  normally  found,  particularly  in  negroes,  in  the  neighborhood  of  its- 
basilar  insertion. 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   229- 

and  translucent,  in  no  connection  with  the  dura,  with  an 
irregular  thin  margin,  and  gaps,  and  are  probably  the  re- 
sult of  the  calcareous  transformation  of  lymph  exudations. 
The  writer  has  never  found  them  to  have  the  true  bony 
structure  of  the  osseous  plates  found  on  the  dura,  although 
some  authors  claim  that  bone  corpuscles  occur  in  them. 

A  most  important  feature  of  a  number  of  cases  of  paretic 
dementia  is  so-called  haemorrhagic  pachymeningitis.  It  was 
found  in  three  out  of  fifteen  cases  of  paretic  dementia  ex- 
amined post  mortem  by  the  writer,  and  in  one  case  com- 
bined with  a  corresponding  condition  of  the  spinal  dura. 
Baillarger  observed  this  lesion  in  one  eighth,  and  Mendel  in 
nearly  a  third  of  his  cases.  In  two  of  the  three  cases 
recorded  by  the  writer  an  extensive  meningeal  haemorrhage 
accompanied  this  lesion,  and  in  one  of  them  the  patient, 
whose  spinal  dura  showed  intense  pachymeningitis,  this 
haemorrhage  extended  from  the  olfactory  lobes  down  to 
the  lumbar  enlargement  of  the  cord. 

In  the  earliest  stages  of  haemorrhagic  pachymeningitis 
the  inner  layer  of  the  dura  is  said  to  exhibit  a  rosy  tinge, 
due  to  a  vascular  hyperaemia.  This,  according  to  Virchow 
and  Kremiansky,  is  followed  by  an  exudation  of  formed 
elements  of  the  blood  which,  in  their  union  on  the  inner 
face  of  the  membrane,  constitute  a  delicate  neomembrane. 
It  is  a  question  whether  the  exudation  is  a  genuine  dia- 
pedesis  or  a  haemorrhage,  but  the  writer's  observations 
support  the  probability  of  the  latter  occurrence.  He  be- 
lieves that,  in  a  considerable  number  of  cases,  a  haemor- 
rhage, not  from  the  dura  but  from  the  leptomeninges,  is  the 
primary  lesion;  that  the  greater  portion  of  the  exuded 
blood  is  resorbed,  but  that  the  portion  nearest  the  dura 
becomes  organized  and  attached  to  it  in  the  manner  de- 
scribed by  Huguenin.  The  leucocytes  become  transformed 
into  spider-shaped  connective  tissue  cells,  whose  processes 
uniting  form  the  ground  net-work  for  a  new  connective 
tissue  in  which  blood-vessels  with  very  fragile  walls  are 
developed.  These  grow  from  the  dura  and  extend  into  the 
new  formation,  and  their  development  indicates  a  second- 
ary irritation  of  the  dura  proper.  A  renewed  hyperaemia 
may  lead  to  the  rupture  of  these  feeble  vessels,  and  a 
second  haemorrhage  then  occurs  between  the  neomembrane 
and  the  dura,  or  between  the  different  layers  of  the  neo- 
membrane. The  same  histological  metamorphosis  then 
takes  place  in  the  new  clot,  and  haemorrhage  after  haemor- 


230  INSANITY. 

rhage  may  recur  until  the  enormous  blood  cysts  known  as 
hcRinatomata  *  of  the  dura  mater  are  formed. 

A  strong  support  for  the  view  of  Huguenin,  that  the 
haemorrhage  is  the  primary  factor,  is  derived  from  the  fol- 
lowing considerations:  It  is  well  known  that  haematomata 
and  other  signs  of  pachymeninigitis  interna  are  not  onl}- 
found  with  paretic  dementia  and  traumatism,  but  also  with 
alcoholism,  apathetic  and  senile  dementia,  epilepsy,  and 
phthisis.  In  several  of  these  disorders  positive  signs  of 
lesion  of  the  dura  proper  are  absent;  indeed,  in  that  stage 
of  the  neomembranous  formation,  when  it  represents  a  sort 
of  rust-colored  lining  of  the  dura,  the  inner  epithelium  of 
the  latter  membrane  may  be  found  intact;  while  there  is  at 
first,  as  Huguenin  has  shown,  no  tissue  connection  between 
the  two.  Then  again,  large  haematomata  are  found  as 
sequelae  of  brain  atrophy,  and  in  that  event  we  may  be  sur- 
prised to  find  enormous  blood  cysts,  whose  existence  no 
symptom  observed  during  the  life  of  the  patient  could  have 
induced  us  to  suspect.  It  would  be  remarkable — if  the 
haematoma  were  always  the  result  of  an  inflammatory  proc- 
ess of  the  dura — that  pain,  ordinarily  so  prominent  a 
symptom  when  that  membrane  is  affected,  should  be 
entirely  absent  in  some  cases.  Mendel  thinks  it  inconsist- 
ent that  if,  as  Huguenin  claims,  the  neomembrane  were  a 
metamorphosis  from  a  haemorrhage,  no  traces  of  blood  pig- 
ment should  be  discoverable  in  some  cases.  Against  this 
objection  the  writer  has  a  remarkable  observation  to  ad- 
vance. In  a  case  of  katatonia,  on  the  verge  of  terminal 
deterioration  and  complicated  by  a  pulmonary  affection, 
which  proved  fatal,  a  gelatinous  material  was  found  in  the 
meshes  of  the  arachnoid  which  had  a  very  pale  rusty  tinge, 
but  was  quite  transparent,  and  at  some  places  attached 
loosely  to  the  dura  as  a  thin  film.  Microscopically 
this  material  was  found  to  be  almost  entirely  composed 
of  red  blood  corpuscles — at  least,  bodies  resembling  in 
every  way  red  blood  corpuscles  deprived  of  their  color, 
after  exposure  to  the  action  of  aqueous  solutions.  A  very 
few  black  pigment  granules,  some  streaks  of  fibrin,  and 
a  large  number  of  white  corpuscles  were  the  only  other 
elements  discoverable.  It  required  no  extravagant  specu- 
lation to  imagine  that  the  material  in  the  meshes  of  the 
arachnoid  was  destined  to  undergo  a  liquefaction  and  ab- 

*  Durhaematomata. 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   23 1 

sorption,  while  that  near  the  dura  was  preparing  to  con- 
tract a  permanent  union  with  that  membrane,  in  which 
event  it  would,  had  the  patient  lived  longer  and  the  mem- 
brane had  time  to  become  organized,  have  presented  itself 
as  one  of  those  rusty-colored  pseudo-membranous  patches 
of  the  dura,  in  which  the  pathologist  finds  but  few  if  any 
indications  of  pigment.  Another  objection  of  Mendel  al- 
most answers  itself.  That  writer  finds  it  difficult  to  under- 
stand how,  if  Huguenin's  theory  is  true,  a  fresh  haemorrhage 
could  be  included  in  a  haematoma,  and  entirely  separated 
from  the  dura  by  newly-formed  tissue.  On  referring  to- 
his  excellent  plate  illustrating  the  lesion  in  question,  the 
inner  durai  epithelium  is  found  to  be  nearly  intact,  and  the 
transition  between  the  "fresh  haemorrhage"  and  the  periph- 
eral parts  of  the  neomembrane  as  delineated  is  so  grad- 
ual that  it  is  a  matter  of  doubt  whether  the  two  were  not 
coeval  in  origin.  At  any  rate,  the  statement  of  Huguenin, 
that  newly-formed  and  fragile  blood-vessels  penetrate  from 
the  dura  into  the  neoplasm,  covers  the  possible  occurrence 
of  an  early  haemorrhage. 

The  changes  of  the  arachnoid  and  pia  may  be  considered 
together.  A  chronic  form  of  leptomeningitis  (inflammation 
involving  both  these  membranes),  with  connective  tissue  new 
formation,  and  milky  opacity,  rather  than  purulent  infiltra- 
tion as  a  result,  is  one  of  the  more  common  gross  findings 
in  paretic  dementia.  The  laminae  of  the  arachnoid  bridging 
the  convolutions  are  with  this  unusually  firm,  and  the  pia 
is  found  abnormally  adherent  to  the  cortex,  sometimes 
over  the  entire  surface,  but  usually  only  in  insulated  places, 
particularly  at  the  apices  of  the  convolutions.  The  oppo- 
site condition,  an  abnormal  looseness  of  the  pia,  is  some- 
times found,  and  authors  have  described  cases  where  this 
membrane  was  raised  in  blebs  from  the  surface  by  fluid 
accumulations.  This  separation  is  probably  due  to  the 
formation  of  a  pathological  sub-pial  space,  bearing  the 
same  relation  to  the  true  lymph  meshes  of  the  brain  en- 
velopes that  the  pathological  perivascular  space  of  His  bears 
to  the  true  adventitial  space. 

Among  the  organs  outside  of  the  cranial  cavity  which 
are  found  diseased  in  paretic  dementia,  the  spinal  cord  de- 
serves the  first  place,  for  its  morbid  processes  are  often 
anatomically  continuous  with  those  of  the  encephalon. 
Thus  arachnoid  haemorrhage,  changes  in  the  dura,  and  in- 
flammation of  the  surface  are  found  involving  the  envelopes 


232 


INSANITY. 


of  the  brain  and  cord  simultaneously;  while  sclerotic 
changes  are  sometimes  traceable  from  one  to  the  other. 
Again,  there  are  cases  where  clinical  observation  demon- 
strates that  the  coarser  anatomical  changes  must  have 
begun  in  the  cord,  and  involved  the  brain  secondarily. 

While  sclerosis  of  the  posterior  columns  of  the  cord,  in 
the  distribution  which  is  typical  of  locomotor  ataxia,  is 
sometimes  found  in  paretic  dements,  a  less  fascicular  and 
symmetrical  form  of  sclerosis  is  more  common.     Sometimes 

Fig.  7.* 


it  is  peripheral  and  the  result  of  a  meningo-myelitis,  more 
commonly  it  is  distributed  as  shown  in  the  figure,  and 
seems  to  originate  in  a  sclerosis  of  the  blood-vessels,  and  a 
subsequent  development  of  a  formless  connective  tissue, 
with  an  occasional  Deiter's  or  spider-shaped   cell.     To  the 


*  Transverse  section  of  the  spinal  cord  from  an  advanced  paretic  de- 
ment. /',  sclerotic  patch  in  the  posterior  column  apparently  concen- 
trated around  a  sclerotic  blood-vessel;  c,  collateral  sulci,  with  sclerotic 
patches  in  their  depths:/,  posterior  fissure,  with  abnormal  ectasies  (lym- 
phatic) at  J,  s;  V,  \  ascular  spaces  (normal)  of  gray  substance. 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   233 

naked  eye  the  gray  matter  of  such  a  cord  appears  normal, 
while  a  reddish-gray  discoloration  of  the  region  bordering 
the  collateral  sulci  and  the  deeper  portions  of  the  posterior 
columns  indicates  their  diseased  condition.  The  discolored 
patches  are  firm.  Under  the  microscope  it  is  found  that 
slight  changes  similar  to  those  in  the  posterior  columns 
exist  in  the  lateral  columns,  particularly  near  the  reticular 
processes.  An  exquisite  example  of  the  vesicular  degenera- 
tion described  by  Leyden  was  found  in  two  cases  by  the 
writer,  who  believes  the  vesicular  spaces  to  be  tubular  in 
character,  and  to  contain  fluid  or    semi-fluid  contents  of 

Fig.  8.* 


the  nature  of  myelin  or  some  product  of  the  degeneration 
of  myelin.  Often  they  contain  one  or  more  axis  cylinders, 
and  a  glance  at  the  specimen  suggests  the  probability  of 
these  tubular  spaces  being  the  product  of  the  fusion  of 
several  hypertrophying  myelin  tubes,  accompanied  by  ob- 
literation of  the  neurilemma,  and  subsequent  degeneration 
of  the  axis  cylinders.     Granular  cells  are  sometimes  found 

*  Section  magnified  500  diameters  from  one  of  the  sclerotic  patches  of 
Fig.  7.  Two  sclerotic  vessels  are  cleary  recognizable,  their  lumina  being 
nearly  obliterated.  The  neurilemma  is  hypertrophied  (rendered  too 
coarsely  granular  in  the  cut),  and  large  nuclei  are  found  scattered  in  the 
formless  connective  tissue  which  constitutes  this  hypertrophy. 


234  INSANITY. 

in  and  between  these  spaces;  these  bodies  seem  to  be  leu- 
cocytes, which  have  taken  up  the  products  of  myelin  disin- 
tegration. A  strict  line  of  division  is  to  be  drawn  between 
these  bodies  and  the  so-called  "granule  cells"  of  several 
authors,  which  can  be  conclusively  shown  to  be  not  cells, 
but  fragments  of  disintegrated  nerve  tubules,  whose  car- 
mine-absorbing centre  (so-called  nucleus)  is  an  axis  cylinder 
fragment,  and  whose  supposed  protoplasm  is  the  granularly 
degenerating  myelin.  Frommann's  cells  are  sometimes 
observed  in  large  numbers  in  the  sclerotic  areas. 

In  one  case — that  of  a  negro  paretic  with  cerebro-spinal 
pachymeningitis — the  writer  found  a  fascicular  softening  in- 
volving the  left  lateral  column,  and  only  a  millimetre  and 
a  half  in  diameter,  though  it  extended  for  the  entire  length 
of  the  dorsal  and  cervical  cord.  Associated  with  this  there 
were  wedge-shaped  sclerotic  patches  from  the  level  of  the 
first  to  that  of  the  eighth  dorsal  nerve  exits.  The  w'hole 
area  of  the  transverse  section  of  the  cord  was  of  a  dirty 
yellowish  tint.* 

The  ganglionic  groups  of  the  anterior  horn  frequently 
show  marked  changes  in  advanced  paretic  dementia,  of  a 
kind  similar  to  that  found  in  locomotor  ataxia  of  long  stand- 
ing. In  such  cases  the  coexistence  of  trophic  disturbances 
has  been  noted  by  Kiernan.  The  nerve  bodies  appear  to 
be  sclerotic,  their  processes  break  off  easily,  and  their  pro- 
toplasm contains  immense  accumulations  of  a  yellow  or 
brown  coarsely-granular  material,  the  precise  chemical 
nature  of  which  it  is  difficult  to  determine.  In  some  bodies 
no  nucleus  can  be  seen,  it  being  destroyed  or  obscured  by 
this  morbid  deposit  which,  as  shown  in  the  accompanying 
cut  (Fig.  9),  may  almost  fill  the  protoplasmic  area.  At  the 
same  time  the  bodies  are  fewer  in  number  than  in  the 
normal  cord,  and  residua  of  destroyed  ganglionic  bodies 
are  found,  though  much  less  frequently  than  in  the  cortex. 
In  one  case  the  writer  found  the  nerve  bodies  of  the  anterior 
horn,  yellow  in  color,  not  taking  up  carmine,  and  with  few 
or  no  traces  of  a  nucleus — a  condition  which,  as  stated,  is 
also  found  in  the  cortex  of  the  hemispheres. 

The  nerve  roots  may  show  all  the  changes  found  in  pos- 
terior sclerosis  in  those  cases  where  the  spinal  lesion  is 
marked.     In  the  majority  of  cases  they  exhibit  no  apprecia- 

*  A  similar  discoloration  was  noted  in  nearly  all  the  medullary  districts 
of  the  brain  of  the  same  patient. 


THE    MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   235 

ble  diminution  in  size,    nor  any  change  in  color  or  con- 
sistency. 

Much  interest  has  been  awakened  by  the  claim  of  Poin- 
care  and  Bonnet,  that  the  sympathetic  ganglia  show  the 
most  constant  lesions  in  this  disease.  While  these  ob- 
servers based  too  sweeping  a  generalization  on  their  find- 
ings, it  is  worthy  of  note  that  in  one  case,  where  there  were 
pronounced  trophic  disturbances,  the  writer  found  a  larger 
number  of  cells  than  usual  with  double  nuclei,  thickening 

Fig.  9.* 


of  the  cell  capsules,  and  multiplication  of  the  free  nuclei 
between  them  in  the  interspinal  ganglia,  as  well  as  pig- 
mentary degeneration  of  the  inferior  and  superior  cervical 
ganglia. 

The  optic  papilla  is  most  constantly  affected  in  that  form 
of  paretic  dementia  which  complicates  locomotor  ataxia. 
In  one  case  of  this  kind,  noteworthy  for  the  youth  of  the 
patient  who  was   only  twenty-three,  the  writer  found  white 

*  Changes  in  the  large  nerve  bodies  of  the  anterior  horn  of  the  same 
cord  represented  in  Fig.  7.  In  the  upper  part  there  is  an  apparently 
healthy  body;  the  long  ganglionic  body  shows  the  nucleus  and  granular 
clump  side  by  side;  in  the  lowermost  one,  the  clump  occupies  nearly  the 
whole  protoplasmic  area. 


236  INSANITY. 

atrophy  of  both  papillae.  In  an  old-standing  case,  clini- 
cally a  typical  paretic  dementia,  but  with  which  a  luetic 
nature  was  probable,  there  was  sclerosis  of  the  temporal 
side  of  the  papillae,  and  a  corresponding  defect  of  vision 
on  the  right  side,  while  the  left  eye  appeared  healthy.  A 
third  case  of  this  disease,  in  which  there  were  photopsia 
and  extensive  hallucinations  of  fiery  visions  (page  202), 
showed  marked  hyperaemia  of  both  papillae.  These  were 
the  only  cases  of  pronounced  retinal  disease  or  disturbance 
observed  in  eighteen  asylum  patients  examined.  In  thirty- 
nine  cases  in  private  practice  in  which  ophthalmoscopic  ex- 
aminations could  be  made,  there  was  found  optic  nerve 
atrophy  in  three  cases,  choked  disk  in  one,  and  a  pronounced 
hyperaemia  in  four;  the  single  female  case  had  the  most 
pronounced  atrophy  found  in  this  disease  by  the  writer. 

Such  assertions  as  those  of  Clifford  Albutt,  who  claimed 
that  the  papilla  was  atrophied  in  forty-one  out  of  fifty- 
three,  less  severely  affected  in  seven,  and  healthy  in  only 
five  cases,  are,  to  say  the  least,  startling. 

The  changes  of  other  organs  and  structures,  such  as 
those  of  the  lungs,  heart,  stomach,  and  bowels,  the  bones 
and  skin,  inasmuch  as  they  are,  as  far  as  an  intrinsic  rela- 
tion to  paretic  dementia  is  concerned,  secondary  to  the 
cerebral  disorder,  and  have  a  similar  pathology  and  etiol- 
ogy as  the  same  changes,  studfed  by  the  general  neurologist, 
require  no  detailed  consideration  here. 

THE  RELATION  BETWEEN  THE  LESIONS  OF  THE  NERVOUS  SYSTEM 
AND  THE  SYMPTOMS  OF  PARETIC  DEMENTIA. 

As  previously  indicated  the  majority  of  those  patholo- 
gists engaged  in  the  study  of  morbid  changes  which  are 
most  frequently  found  in  paretic  dementia  have,  through 
the  frequent  discovery  of  material  and  destructive  lesions 
of  the  cerebral  cortex,  been  led  to  consider  this  disease  as 
an  essentially  inflammatory,  or  at  least  as  a  degenerative, 
process.  While  this  is  true  with  regard  to  the  terminal 
and  active  phases  of  the  disorder,  it  is  a  question  whether 
the  condition  of  the  brain  in  the  earlier  periods  of  paretic 
dementia  justifies  us  in  assuming  an  inflammatory  or  de- 
generative change  to  exist  from  the  beginning. 

If  the  intrinsic  factor  of  the  morbid  process  underlying 
this  disease  were  an  inflammation,  or  a  primary  progressive 
histological  deterioration,  the  evidences  of  these  conditions, 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.    237 

which  are  readily  discovered  and  unmistakable,  would  be 
found  in  the  brain  of  every  paretic  who  reaches  the  au- 
topsy table.  This,  however,  is  not  the  case.  Well-authen- 
ticated instances  are  on  record  where  no  marked  lesion  was 
discoverable,  and  one  of  the  most  reliable  investigators* 
in  this  field  takes  special  occasion  to  mention  this  fact.  In 
the  writer's  experience,  one  case  has  occurred  in  which 
nothing  was  found  beyond  the  ordinary  appearances  pre- 
sented by  the  brains  of  sane  persons,  excluding  the  stasis- 
like condition  above  described,  and  which  can  be  interpre- 
ted neither  as  a  degenerative  nor  as  a  strictly  inflamma- 
tory process  in  the  ordinary  acceptation  of  the  term. 

Then  again,  if  a  degenerative  or  inflammatory  process, 
or,  in  short,  any  profound  tissue  change  were  the  funda- 
mental lesion  of  this  interesting  disease,  it  should,  in  its  ex- 
tensity  and  intensity,  stand  in  a  rather  constant  relation  to 
the  amount  and  character  of  the  mental  disturbance.  This 
has  been  found  to  be  so  in  all  cases  which  had  run  a  long 
course;  but,  in  several  others  which  had  terminated  within 
two  years  from  the  date  of  the  first  manifestations,  the 
writer  failed  to  find  any  harmony  between  the  extent  and 
severity  of  the  tissue  lesions  and  the  symptoms. 

It  was  the  consideration  of  this  fact  that  led  Poincare 
and  Bonnet  to  search  in  the  sympathetic  ganglionic  sys- 
tem for  those  disturbances  which  the  brain  refused  to 
reveal.  That  they  mistook  appearances  occasionally  oc- 
curring in  health  for  disease,  and  secondary  processes  for 
primary  lesions,  does  not  detract  from  the  value  of  the 
principle  they  were  endeavoring  to  establish,  though  their 
observations  as  observations  cannot  be  utilized  to  support 
it.  As  we  have  seen,  changes  in  the  sympathetic  ganglia 
are  sometimes  found,  but  they  are  much  less  pronounced 
than  those  of  the  central  nervous  system. 

It  is  more  than  probable  that  the  vaso-motor  system  con- 
trolling the  cerebral  circulation  is,  at  least  in  part,  in  the 
brain  itself,  and  that  its  initial  disturbances  are  as  little 
tangible  to  the  microscope  as  they  are  with  other  disturb- 
ances of  the  same  system — for  example,  in  epilepsy. 

The  most  furibund  of  the  symptoms  ever  manifested  by 
paretics  are:  First,  high  maniacal  explosions,  with  great 
destructive  tendencies,  and  often  with  rapid  flight  of  ideas; 
second,  apoplectiform  attacks;   third,  epileptiform  attacks. 

*Theo.  Simon.      "  Die  Gehirnerweichung  der  Irren."     Hamburg,  1871. 


238  INSANITY. 

The  first  of  these  symptoms,  which  is  not  at  all  as  con- 
stant as  is  generally  supposed,  is  found  in  its  most  perfect 
development  in  early  periods  of  the  disease.  It  appears  as 
if  the  profound  lesions  ensuing  in  the  later  stages  of  the 
affection  were  inimical  to  its  full  development.  The  sec- 
ond is  found  variably,  more  frequently  and  fatally  in  the 
last  stages.  The  third  is  also  found  variably  and  more 
frequently  in  the  last  stages  of  the  disease,  but  exception- 
ally convulsions  are  the  very  first  evidences  of  the  latter. 
Each  maniacal,  apoplectic,  or  epileptiform  exacerbation 
leaves  the  patient  permanently  more  crippled  than  before, 
either  in  his  motor  or  psychical  field;  rarely,  however,  the 
contrary,  a  relatively  complete  restitutio  ad  integrum,  takes 
place. 

A  patho-physiological  theory  of  the  disease  must  take 
into  account  and  harmonize  all  these  facts.  It  must  offer 
an  explanation  for  the  facts  that  the  maniacal  explosions 
are  less  perfect  in  the  last  than  in  earlier  stages  of  the 
disease;  that  tlie  most  violent  symptoms  may  occasionally 
open  the  clinical  picture;  that,  as  a  rule,  each  exacerbation 
leaves  the  patient  worse,  though  a  remission  and  temporary 
improvement  are  not  out  of  the  question. 

The  supposition  of  a  strictly  inflammatory  process  is  in- 
compatible with  the  occasional  appearance,  as  the  first  evi- 
dences of  the  disease,  of  epileptiform  spasms  which  are  not 
followed  by  those  immediate  sequelae  ordinarily  following 
such  an  inflammation.  It  is  incompatible  with  the  very 
rapid  and  relatively  complete  remission  of  the  symptoms.  It 
is  also  known  that  certain  of  the  injurious  physical  influen- 
ces provoking  the  disease,  such  as  violence  directly  or  indi- 
rectly affecting  the  cranium,  and  insolation  as  well  as  other 
forms  of  overheating,  do  not  always  act  on  the  brain 
through  the  channel  of  a  meningitis  or  other  inflammatory 
process.* 

All  these  facts  can  be  harmonized  by  assuming  the  essen- 
tial and  primitive  anomaly  in  the  paretic's  brain  to  be  a 
vaso-motor  disturbance.  This  assumption  is  in  strict  ac- 
cordance with  the  observations  made  on  the  brain  after 
death. 

In  every  case  where  the  patient  died  in  a  maniacal  attack, 

*  In  Arndt's  cases  (soldiers  dying  from  overheating  after  a  forced 
march)  the  majority  showed  a  pale  brain,  without  visible  morbid  ap- 
pearances. 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA,    239 

or  shortly  after  such  a  one,  or  in  an  epileptiform  state,  or 
with  apoplectiform  symptoms,  the  writer  constantly  found 
the  capillary  thrombi,  which  with  Lubimoff  he  considers  to 
be  the  expression  of  a  blood  stasis.  That  stasis  is  to  be  re- 
garded as  the  result  of  a  paralysis  of  the  muscular  coat  of 
the  blood-vessels,  over-distended  by  the  efferent  blood  col- 
umn, in  its  turn  an  indication  of  hyperaemia. 

A  cortical  hyperaemia  would  explain  the  expansive  idea- 
tion, and  the  motor  excitation;  the  arrest  of  the  blood  cur- 
rent through  stasis,  the  subsequent  congestive  and  coma- 
tose states.  A  sudden  stasis,  causing  sudden  arrest  of  the 
cortical  functions,  would  satisfactorily  account  for  the  epi- 
leptic manifestations.  A  cortical  hyperaemia,  as  a  factor 
that  may,  on  the  one  hand,  vanish  with  the  most  violent 
storm  sweeping  over  the  mental  plain,  without  leaving  a 
permanent  defect;  and,  on  the  other  hand,  in  its  repeated 
recurrence,  determine  those  structural  changes  which 
account  for  the  permanent  symptoms  of  the  disease,  would 
also,  in  its  necessarily  progressive  severity,  account  for  the 
progressive  greater  gravity  of  each  exacerbation,  and  the 
final  preponderance  of  symptoms  of  subtraction  such  as 
paralysis,  lacunae  in  the  memory,  aphasia  and  coma,  over 
those  of  functional  excitation,  such  as  the  destructive  ten- 
dencies, constructive  scliemes,  ambitious  delusions,  and 
flight  of  ideas  of  the  earlier  periods. 

As  the  disease  progresses,  and  the  resisting  tone  of  the 
vessels  decreases  more  and  more,  stases  are  found  to  occur 
not  only  in  the  exacerbations  of  the  disease,  but  also  in  the 
intervals;  here  more  restricted  in  extent  and  less  pro- 
nounced, so  that  with  proper  methods  of  preparing  histo- 
logical specimens  the  writer  believes  that  no  lesion  will  be 
found  so  constantly  in  the  terminal  periods  of  the  disease 
as  the  capillary  thrombi  resulting  from  such  stases. 

Of  course,  with  this  explanation  we  are  as  much  in  the 
dark  as  ever  as  to  the  organic  basis  of  the  vaso-motor  diffi- 
culty. As  above  stated,  this  consists  in  a  probably  impal- 
pable morbid  state  of  the  encephalic  vaso-motor  centre. 
Such  a  morbid  state  it  requires  no  stretch  of  theory  to 
consider  inducible  b}'  mental  overstrain,  by  the  repeated 
hyperaemias  of  alcoholism,  rheumatism,  and  certain  forms 
of  syphilis,  or  by  typhus  fever,  insolation,  and  the  molecular 
disturbances  determined  by  concussion,  directly  or  indirectly 
involving  the  skull  contents.  While  the  essential  factor  in 
the  development  of  paralytic  dementia  would,  in  this  light, 


240  INSANITY. 

be  constituted  by  the  vaso-motor  difficulty,  a  direct  influ- 
ence of  many  of  the  causes  supposed  and  known  to  provoke 
disease  of  the  cerebral  tissues  need  not  be  excluded.  In 
fact,  for  some  of  the  syphilitic  forms  and  those  cases  in 
which  the  writer  believes  a  multiple  sclerosis  to  be  the 
essential  lesion  this  seems  to  be  the  case,  and  we  may 
some  day  have  to  draw  a  line  between  those  cases  with 
which  the  vaso-motor  anomalies  are  in  the  foreground,  and 
those  with  which  they  are  in  the  background. 

A  careful  study  of  certain  cases  of  cerebro-spinal  sclerosis, 
constituting  connecting  links  between  the  t\^pical  disease 
and  "chronic"  varieties  of  dementia,  may  yet  show  that 
vaso-motor  derangement  plays  a  far  more  important  role 
also  in  that  disease  than  is  generally  imagined.  Apoplecti- 
form and  congestive  attacks  are  also  encountered  here,  and 
they  present  many  points  of  resemblance  to  those  of  genuine 
paretic  dementia.  When  it  is  recollected  that  a  large  per- 
centage of  the  cases  of  multiple  sclerosis  is  ascribed  to 
concussion  as  a  cause,  by  Erb  and  other  authors,  the  attrib- 
uting of  certain  cases  of  paralytic  dementia  to  the  same  cause 
by  prominent  alienists  merits  renewed  attention,  as  bearing 
on  the  vaso-motor  etiology  of  the  disease.  In  this  connec- 
tion it  may  be  well  to  refer  to  some  remarkable  analogies 
of  paretic  dementia,  with  typical  posterior  spinal  sclerosis. 
Both  diseases  are  more  .common  in  the  male  than  in  the 
female,  and  under  certain  circumstances  occur  nearly  in  the 
same  proportion  in  the  sexes.  Both  have  been  attributed 
to  sexual  excess  as  a  cause.  With  regard  to  both  the 
syphilitic  dyscrasia  plays  the  same  role.  Cranial  or  spinal 
symptoms  may  open  the  history  of  either,  and  these  symp- 
toms show  a  striking  analogy.  Thus  amblyopia  and  di- 
plopia may  be  the  first  indications  of  posterior  sclerosis,  so 
may  color-blindness,  optic  nerve  atrophy,  and  diplopia  be 
the  first  signs  of  paretic  dementia.  The  essential  cerebral 
signs  of  paretic  dementia  may  be  complicated  by  the  typi- 
cal picture  of  posterior  sclerosis;  so  the  latter  may  be  com- 
plicated by  paretic  dementia.  Paretic  dementia  is  patho- 
logically a  progressive  brain-tissue  deterioration,  which  is 
the  basis  of  the  progressive  and  constant  symptoms  of  sub- 
traction found  in  this  disease;  while  certain  episodes — 
maniacal,  apoplectiform,  epileptiform,  and  trophic  accidents 
— mark  its  progress,  which  cannot  be  explained  by  that 
lesion  alone.  Similarly,  posterior  sclerosis  is  pathologically 
a  tissue  degeneration  of  a  considerable  part  of  the  cord. 


THE   MORBID   ANATOMY   OF   PARETIC   DEMENTIA.   24I 

and  certain  phenomena  are  constant  and  progressive  in  its 
clinical  history,  and  can  be  explained  by  its  lesions;  but 
there  are  episodes  such  as  gastric,  nephritic,  and  other  crises 
which  cannot  be  accounted  for  by  the  lesion  alone;  and 
some  of  these  episodes,  like  the  acute  maniacal  outbreaks 
exceptionally  observed,  show  that  they  may  even  assume  a 
psychical  character.  In  short  paretic  dementia  and  pos- 
terior spinal  sclerosis  appear  to  be  similar  if  not  patho- 
logically identical  processes,  only  differing  in  their  location, 
the  former  being  concentrated  in  the  brain,  the  latter  in 
the  cord. 

There  are  a  number  of  facts  which  point  to  the  early 
involvement  of  the  brain  isthmus  *  in  paretic  dementia. 
In  the  first  place,  the  morbid  changes  are  frequently  ob- 
served to  be  further  advanced  here  than  in  the  cerebral 
cortex.  In  the  second  place,  not  only  the  paralytic  phe- 
nomena indicating  an  affection  of  the  nerve  nuclei  and  the 
emerging  roots,  but  also  certain  emotional  disturbances, 
point  to  the  oblongata  and  pons  as  the  seats  of  at  least 
a  functional  disturbance.  Reference  is  here  particularly 
made  to  the  fact  that  paretic  dements  exhibit  emotional 
manifestations  opposed  to  their  true  emotional  state;  thus, 
while  relating  a  pleasant  reminiscence,  such  a  patient  may 
burst  into  tears,  and,  while  complaining  of  an  affront  or 
of  persecutions,  smile.  Similar  disturbances  are  noted  in 
organic  disease  of  the  medulla  oblongata. f 

This  view  is  also  supported  by  the  fact,  that  at  certain 
periods  in  the  progress  of  spinal  disease,  when  the  morbid 
process  reaches  the  oblongata,  mental  symptoms  develop, 
which  are  strikingly  like  those  of  paretic  dementia,  and 
imitate  both  the  "melancholic"  and  "maniacal"  types  of 
that  disease. 

Grouping  together  all  that  is  known  about  the  interest- 
ing affection  we  are  considering,  and  amalgamating  the 
clinical  and  anatomical  facts  with  the  physiological  theory, 
the  conclusion  follows,  that  paretic  dementia  is  a  progressive 
deterioration  of  the  central  nervous  system,  chiefly  affecting  the 
brain,  and  the  result  of  a  chronic  inflammatory  process  of  an 
angioparalytic   nature,  whose  essential   element,   the   vaso-motor 

*  The  medulla  oblongata,  pons,  and  peduncular  region. 

f  In  a  dispensary  patient  with  complete  anarthria,  the  tongue  lying 
motionless  at  the  bottom  of  the  mouth,  this  was  noted  as  a  salient  symp- 
tom of  the  organic  disease  (tumor  of  the  medulla?)  from  which  she 
suffered. 


242  INSANITY. 

weakening,  is  due  to  overstrain  of  the  encephalic  vaso-nwtor  centre, 
the  exacerbating  and  retnitting  course  of  the  malady,  being  the 
clinical  expression  of  the  struggle  of  that  centre  to  regain  its 
equilibriu7n. 

Owing  to  the  multiplicity  of  lesions  found  in  advanced 
»cases  of  this  disease,  it  is  but  rarely  possible  to  establish  a 
relation  between  localized  lesions  and  special  symptoms. 
As  to  the  most  essential  symptoms  from  the  alienist's 
standpoint,  the  mental  disturbances,  the  fact  that  in  paretic 
dementia  there  is  a  diffuse  or  multilocular  disease  of  both 
cerebral  hemispheres,  is  in  such  striking  accord  with  what 
we  know  of  the  seat  of  the  mind  that  we  may  assume  that 
this  disease  is  the  basis  of  the  progressive  mental  failure. 
A  further  localization  of  the  strictly  mental  symptoms  is  im- 
possible, and  we  may  content  ourselves  with  the  assump- 
tion that  the  frequently  lacunar  character  of  the  amnesia 
is  in  harmony  with  the  fact  that  the  cortical  provinces  are 
not  all  equally  diseased,  some  districts  being  relatively  in- 
tact, and  others  destructive!)'  involved. 

It  is  a  significant  fact  that  those  movements  which  depend 
on  the  voluntary  motor  association  of  smaller  muscular 
peripheries  suffer  earlier  than  those  which  depend  on  the 
combination  of  the  coarser  groups.  This  appears  to  be  in 
parallelism  with  the  fact  that  the  lesions,  at  first  of  slight 
extent,  involve  the  smaller  cortical  areas,  and  subcortical 
associating  fibres  more  completely  than  the  larger  areas 
and  deeper  tracts,*  which  are  seriously  involved  only  in 
the  later  stages  of  the  disease.  It  is,  however,  very  diffi- 
cult to  obtain  much  valuable  material  in  support  of  the 
localization  theory  in  paretic  dementia.  If  it  were  onl}-  the 
cortical  gray  matter  that  is  diseased  the  subject  would  be 
difficult  enough,  but  there  are  also  found  changes  in  the 
lower  segments  of  the  nerve-axis  which  must  have  an  im- 
portant influence  on  the  motor  and  sensor}-  functions,  and 
which  must  be  taken  into  account. 

Thus  the  sclerotic  patches  in  the  course  of  the  cranial 
nerves,  the  raphe,  and  other  important  tracts,  the  degenera- 
tive changes  in  the  nerve  nuclei  of  the  oblongata  and  cord, 
as  well  as  the  disease  processes  in  the  cord,  account  for 
many  of  the  ataxic,  paretic  and  paraesthetic  plienomena  of 

*  The  fibrcE  arcuatce  s.  propria,  which  unite  adjoining  cortical  areas, 
run  immediately  underneath  the  cortex;  those  uniting  more  distant  areas 
run  more  deeply. 


SYPHILITIC   DEMENTIA.  243 

the  disease.  The  speech  defect  in  paretic  dementia  may,  as 
in  the  patient  whose  medulla  oblongata  is  figured  on  page 
224,  be  of  the  anarthric  type,  that  is,  not  truly  aphasia,  and 
hence  not  referable  to  the  lesion  of  the  hemispheres.  The 
only  really  valuable  contribution  to  the  study  of  the  areas 
of  specialized  function  in  the  cortex  is  that  made  by  Fiirst- 
ner,  who  found  that  visual  disturbances  of  the  kind  experi- 
mentally produced  by  Munk,  by  destruction  of  the  occipital 
lobes  in  monkeys,  are  found  in  paretic  dementia  when  there 
is  pronounced  lesion  of  the  posterior  part  of  the  cerebral 
hemispheres.  A  case  in  point  coming  within  the  writer's 
observation  has  been  referred  to  in  the  last  chapter. 


CHAPTER  XIV. 
Syphilitic  Dementia, 


Syphilis  is  an  important  etiological  factor  in  certain 
cases  of  insanity.  In  most  of  these  its  influence  is  rather 
of  a  psychical  than  a  somatic  character,  as  in  the  syphilitic 
hypochondriasis  and  self-accusatory  melancholia  observed 
by  Erlenmeyer,  Here  the  only  direct  influence  of  the  dis- 
ease is  manifested  through  the  associated  impoverishment 
of  brain  nutrition;  and  although  anti-syphilitic  treatment 
is  most  successful  in  combating  these  conditions,  this  does 
not  prove  that  the  brain  state  underlying  them  has  any 
specifically  syphilitic  characters.  The  same  remarks  apply 
to  the  insanity  sometimes  noted  with  the  secondary  fever 
of  syphilis,  and  which  has  not  thus  far  been  demonstrated 
to  be  associated  with  a  palpable  and  constant  change  in 
the  brain  or  its  vessels. 

It  is  different  with  syphilitic  dementia — a  chronic  mental 
disorder  which,  from  its  association  with  anomalies  of  mo- 
tility and  speech,  bears  a  great  resemblance  to  paretic  de- 
mentia and  to  dementia  from  organic  brain  disease.  Here 
demonstrable  brain  lesions,  standing  in  a  constant  relation 
to  the  symptoms,  are  found  in  the  majority  of  cases.  In 
some  cases  syphilitic  pachymeningitis  or  leptomeningitis 
and  gummy  infiltration  of  the  membranes  preponderate;  in 
others  multilocular  gummata  of  the  brain  substance,  or  the 
luetic  arterial  change,  with  its  results,  are  the  most  notable 


244  INSANITY. 

morbid  anatomical  features.  In  one  case  described  by  the 
writer  some  years  ago,  over  a  thousand  perivascular  no- 
dules, single  and  branched,  varying  in  size  from  that  of  a 
pin's  head  to  a  pea,  were  found  scattered  through  the  cere- 
bral tissues  and  associated  with  a  surface  infiltration  of 
the  cortex.  Tlie  pre-lethal  symptoms  in  this  instance  were 
in  no  way  distinguishable  from  those  of  a  maniacal  exacer- 
bation in  a  deteriorated  paretic  dement. 

As  a  rule  the  symptoms  associated  with  these  morbid 
conditions  are  characterized  by  variability,  and  an  almost 
pathognomonic  feature  is  the  accompaniment  of  the  earlier 
mental  symptoms  by  pronounced  paralysis  of  single  mus- 
cles, or  of  definite  muscular  groups  supplied  by  one  or  two 
cranial  nerves.  It  is  an  ordinary  history  of  the  inception 
of  syphilitic  dementia,  that  after  such  prodromal  signs  as 
headache  and  vertiginous  or  syncopal  attacks,  the  patient 
ma\'  awake  with  ptosis,  facial  paralysis,  aphasia,  or  para- 
lytic weakness  of  a  leg  or  an  arm.  These  symptoms  rapidly 
disappear,  and  may  as  rapidly  recur.  With  this  the  patient 
exhibits  lacunae*  in  his  memor\',  an  undue  irritability,  and 
intolerance  to  alcoholic  liquors. 

Clinically  it  is  not  always  possible  to  make  a  sharp  discrim- 
ination between  syphilitic  dementia  and  paretic  dementia 
proper,  for  syphilis  plays  an  important  role  in  the  etiology 
of  the  latter  affection.  Indeed,  Snell  claimed  that  seventy- 
five  per  cent  of  the  cases  of  paretic  dementia  coming  under 
his  observation  were  due  to  syphilis,  a  claim  which  is  in  re- 
markable parallelism  with  that  recently  advanced  by  Erb, 
with  regard  to  locomotor  ataxia,  in  which  a  similar  rela- 
tion is  supposed  to  exist.  Other  authors  find  a  smaller 
proportion  of  syphilitic  paretic  dements  than  Snell.  Mendel 
found  that  of  201  patients  117  were  syphilitic,  and  Ripping 
could  only  detect  a  syphilitic  element  in  about  twelve  per 
cent.  It  is  to  be  borne  in  mind  that  the  mere  co-existence 
of  a  syphilitic  taint  does  not  prove  a  given  form  of  insanity 
to  be  syphilitic;  but  the  fact  is  significant  that,  of  «// syphi- 
litic lunatics,  one  half  are  paretic  dements,  or  suffer  from 
the  allied  form  of  disease  we  are  here  considering. 

In  the  writer's  experience  S}'philis  is  an  etiological  factor 
in  the  production  of  various  forms  of  progressive  dementia 

*Erlenmeyer  calls  attention  to  this  as  a  constant  feature,  and  cites  in- 
stances where  a  special  series  of  events  were  blotted  from  the  mind, 
leaving  other  recollections  intact.     This  is  also  found  in  paretic  dementia. 


SYPHILITIC   DEMENTIA.  245 

in  about  one  third  of  the  cases  among-  the  pauper  insane  of 
New  York.*  Its  existence  could  be  determined  in  fourteen 
per  cent  of  the  paralytic  patients  in  private  practice.  Of 
these  eighty  per  cent  had  typical  paretic  dementia,  and  the 
remainder  the  true  syphilitic  form  of  dementia. 

Numerous  attempts  have  been  made  to  establish  some 
criterion,  on  the  strength  of  which  to  be  able  to  distinguish 
syphilitic  from  typical  paretic  dementia  ;  but  these  do  not 
always  hold  good.  Thus,  it  has  been  supposed  that  the 
association  of  true  locomotor  ataxia  with  paretic  dementia, 
proves  the  syphilitic  origin  of  the  case.  But  there  are  non- 
syphilitic  tabetics  who  become  paretic  dements,  while  there 
are  syphilitic  dements  who  are  not  markedly  tabetic. 
On  the  other  hand,  observers  have  suggested  the  empirical 
test  of  an  anti-syphilitic  treatment,  which  was  supposed,  if 
successful,  to  demonstrate  that  the  disorder  was  of  syphili- 
tic origin. r  But  we  know  that  spontaneously  remissions  fV 
occur  in  ordinary  paretic  dementia,  while  in  unquestioned  / 
syphilitic  cerebral  disease  the  most  energetic  anti- syphilitic 
treatment  may  fail.  The  writer  has  found  that  both  mer- 
cury and  iodide  of  potassium  appeared  to  be  of  service  in 
cases  where  a  luetic  infection  could  be  positively  excluded  ; 
and  Ripping  goes  so  far  as  to  claim  that   he   has  seen  in- 

*  It  was  impossible  to  obtain  accurate  information,  and  the  estimate 
here  given  is  probably  under  the  truth. 

f  This  procedure  has  been  very  faithfully  carried  out  by  Dr.  Allan 
McLane  Hamilton,  who  says:  "  When  an  apparently  strongman  comes  to 
us  with  a  history  of  fugaceous  aches  and  pains,  inconstant  spasms,  and  dis- 
ordered subjective  sensations — notably  among  which  are  subjective  cold 
— we  should  not  immediately  make  light  of  his  troubles,  and  even  dismiss 
him  for  change  of  air  and  scene,  but  empirically,  if  our  history  of  cause 
is  not  clear,  place  him  upon  proper  anti-syphilitic  remedies."  ("Syph- 
ilitic Hypochondriasis  ;  Alienist  and  Neurologist,"  vol.  i.,  No.  i,  page 
79).  Ripping  (Ueber  die  Beziehungen  den  Syphilis  zu  den  Geisteskrank- 
heiten  mit  und  ohne  Liihmungen,  Allg.  Zcitschrift  fuer  Psychiatrie) 
makes  the  following  comment:  "Such  views  as  those  I  above  cited 
from  Allan  McLane  Hamilton,  it  may  be  safely  claimed,  have  no  uphold- 
ers, among  German  physicians  at  least."  As  to  this  remark  it  may  be 
said,  that  it  manifests  a  tone  of  criticism  which  is  becoming  rather  too 
common  in  Germany.  Science  is  international,  and  if  an  absurd  and 
ridiculous  view  is  announced  by  an  American  physician,  that  is  no  justi- 
fication for  raising  an  international  question.  In  the  present  case  the 
implied  inference  that  such  views  as  the  one  criticised  are  shared  by  the 
American  medical  profession  would  be  in  the  highest  degree  unjust;  for 
"  it  may  be  safely  claimed"  that  no  other  American  writer,  nay,  that  no 
other  writer  anywhere,  has  ever  announced  or  held  such  a  view  as  the 
one  which  Ripping — properly  enough — finds  fault  with. 


246  INSANITY. 

sanity  in  syphilitic  subjects  recovered  from,  although  no 
anti-syphilitic  treatment  of  any  kind  had  been  applied. 

After  the  prodromal  period  referred  to,  the  course  of 
syphilitic  dementia  is  progressively,  and  usually  very  slov^dy, 
toward  a  fatal  termination.*  Delusions  are  not  prominent, 
and  rarely  expansive,  though,  in  paretic  dementia  from 
syphilis,  the  unsystematized  delusions  of  grandeur  may  be 
as  well  marked  as  in  non-syphilitic  cases. f  Sometimes  the 
terminal  period  of  an  at  first  clinically  well-marked  syphi- 
litic brain  disorder  is  in  no  way  distinguishable  from  typi- 
cal paretic  dementia. J 

It  is  possible  that  with  the  progressing  accumulation  of 
clinical  and  pathological  material,  syphilitic  dementia  will 
share  the  fate  of  "syphilitic  meningitis,"  which  is  now 
known  to  differ  in  no  essential  respect  from  ordinary  men- 
ingitis, except  in  those  rarer  instances  where  the  specific 
gummatous  character  prevails.  It  is  to  cases  correspond- 
ing to  the  latter  that  the  term  syphilitic  dementia  should 
be  limited. 

*  In  one  case  of  syphilitic  dementia,  closely  approaching  true  paretic  de- 
mentia, a  remission  occurred  which  lasted  four  years,  the  patient,  a  phy- 
sician, returning  to  his  practice.     The  case  has  since  been  lost  sight  of. 

f  Fournier  erroneously  claimed  the  contrary,  and  termed  paretic  de- 
mentia from  syphilis  "  pseudo-paralysie  generale."  Foville  showed  that 
in  syphilitic  paretic  dementia  the  delusions  may  be  as  expansive  and 
varied  as  in  any  case,  and  some  of  the  most  characteristic  delusions  re- 
lated in  the  last  chapter  were  observed  in  syphilitic  patients.  Then,  too, 
it  must  be  recollected  that  in  non-syphilitic  cases,  delusions  may  be  ab- 
sent ;  for  this  reason  alone  Fournier's  claim  would  be  faulty. 

X  Since  the  above  was  written  a  striking  confirmation  of  this  occurred 
in  the  writer's  consultation  practice.  He  was  called  to  examine  a  patient 
who  had  for  a  year  been  under  the  treatment  of  one  of  the  best  clinicians 
in  New  York  for  syphilitic  cerebral  trouble.  For  a  period  of  several 
months  he  improved  considerable  on  anti-syphilitic  medication.  When 
examined  by  the  writer,  he  exhibited  a  lachrymose  hypochondriasis,  with 
some  of  the  motor  symptoms  characterizing  paretic  dementia.  The  diag- 
nosis of  this  disease  was  made.  Two  days  later  he  had  three  epileptiform 
attacks,  and  subsequently  to  these  manifested  gross  amnesia,  hilarity,  ex- 
travagant projects,  and  delusions  ol  physical  strength. 


DELIRIUM    GRAVE.  247 


CHAPTER   XV. 

Delirium    Grave. 

There  is  a  comparatively  rare  form  of  derangement,  ap- 
proximating in  many  respects  to  maniacal  delirium,  and 
yet  distinct  from  it  in  many  essential  features,  vi^hich  has 
been  variously  termed  typ/iomaiiia,  mania  gravis,  phrenitis,  and 
acute  delirimn.  This  disorder  differs  from  the  simple  psy- 
choses in  the  fact  that  it  depends  on  a  stormy  pathological 
process;  and  while  the  motor  excitement  and  the  angry 
fury  of  the  patient  seem  to  be  clinically  only  a  higher 
degree  of  maniacal  furor  or  melancholic  frenzy,  there  are 
somatic  signs  which  justify  the  pathologist  in  comparing 
delirium  grave  to  the  cerebral  disturbances  which  follow 
severe  and  exhausting  febrile  processes,  such  as  pneumonia 
and  typhus.  As  Schiiele  has  aptly  said,  the  symptoms  of  a 
spurious  maniacal  furor  mark  the  first  period  of  the  disease, 
while  the  symptoms  of  grave  cerebral  exhaustion  charac- 
terize the  second.* 

This  disorder  is  more  common  in  females  than  in  males; 
this  is  related  to  the  fact  that  the  puerperal  state  is  often 
found  to  stand  in  a  causal  relation  to  grave  delirium.  It 
is  preceded  and  undoubtedly  caused  by  profound  nervous 
or  physical  exhaustion  and  overstrain.  Schiiele  has  known 
it  to  result  from  excruciating  physical  suffering.  In  most 
cases  it  is  noted  that  the  patient  has  for  a  long  period  of 
time  been  in  a  feeble  state  of  health,  and  that  some  extra 
strain  on  his  nervous  system,  such  as  a  business  crisis, f  an 
alcoholic  excess,  an  emotional  strain, J  or  the  puerperal  state, 
precipitates  the  breaking  out  of  the  delirium. 

The  mental  signs  may  be  briefly  characterized  as  resem- 
bling the  highest  degrees  of  maniacal  furor  and  melancholic 

*  "  Handbuch  der  Geistes-Krankheiten,"  von  Dr.  Heinrich  Schiiele 
("  Ziemssen's  Handbuch"),  vol.  xvi.,  1878). 

f  In  the  case  of  a  lawyer,  who  for  many  months  had  suffered  from  in- 
somnia, this  disorder  exploded  after  the  preparation  of  an  argument. 

X  Abandonment  of  seduced  and  pregnant  girls  is  a  prominent  element 
in  the  history  of  a  number  of  cases. 


248  INSANITY. 

frenzy.*  The)'  differ  from  these  states  in  their  mode  of 
development.  While  maniacal  and  melancholic  frenzy  are 
preceded  by  the  ordinary  and  readily  recognizable  symp- 
toms of  typical  mania  and  melancholia,  the  outbreak  of 
grave  delirium  is  either  sudden  or  preceded  by  a  state  of 
impaired  consciousness  of  a  kind  not  found  in  mania  or 
melancholia  proper.  Thus,  some  patients  in  this  state  ex- 
hibit a  panphobia  like  that  of  febrile  delirium,  while  others 
wander  about  aimlessly,  staggering  as  if  drunk. 

The  ideation  of  grave  delirium  is  much  more  incoherent 
than  of  frenzy,  and  is  usually  the  expression  of  an  angry 
or  a  frightened  state.  While  in  the  beginning  the  patient 
may  still  articulate  sentences,  his  speech  rapidly  deterior- 
ates, and  he  is  finally  unable  to  pronounce  S3'llables.  As 
far  as  the  expressions  of  the  patients  permit  us  to  judge, 
they  have  hallucinator}'  visions  of  the  day  of  judgment,  of 
conflagrations,  of  bloody  scenes,  or  of  those  connected  with 
the  exciting  cause.  Sometimes  a  set  phrase  is  repeated 
over  and  over  again;  usualh'  it  has  some  relation  to  the 
emotional  calamit}'^  provoking  the  outbreak  of  the  disease. 
The  seduced  girl  will  count  as  if  hearing  the  bells  that  toll 
out  the  hour  of  an  assignation,  and  then  suddenly  break  out 
in  a  piercing  cry  or  a  sill}'^  laugh.  The  business  man,  who 
lias  become  delirious  after  a  period  of  business  worry,  re- 
peats figures  or  names  of  articles  of  trade,  of  firms,  or  of 
stocks,  in  an  incoherent  jumble.*  Delusions  of  grandeur  are 


*Schuele  speaks  of  a  melancholic  form  of  acute  delirium  whose  symp- 
toms and  anatomical  basis  are  said  to  be  the  very  reverse  of  the  maniacal 
form.  The  writer  is  unable  to  recognize  in  the  description  anything  but 
a  stupid  melancholia,  developing  on  a  basis  of  extreme  physical  ex- 
haustion. Neither  the  temperature,  nor  the  mental  signs,  nor  the 
relatively  better  prognosis  of  Schiiele's  melancholic  form,  support  his 
view  that  it  is  due  to  as  grave  and  active  a  pathological  process  as  grave 
delirium. 

f  The  recorded  cases  of  "  meningitis  from  over-study"  are  in  fact  cases 
of  grave  delirium.  They  are  brought  about  as  much  by  the  emotional 
strain  attendant  on  competitive  examinations,  as  by  the  mental  effort  itself. 
It  is  never  a  strong  mind  nor  a  healthy  body  that  suffers  in  this  way.  ' '  The 
mental  hygiene"  sensationalists  who  periodically  "enlighten"  the  pub- 
lic through  the  columns  of  the  press,  whenever  an  opportune  moment  for 
a  crusade  against  our  schools  and  colleges  seems  to  have  arrived,  are  evi- 
dently unaware  of  the  existence  of  such  a  disease  as  grave  delirium,  and 
ignorant  of  the  fact  that  the  disorder  which  they  attribute  to  excessive 
study  is  in  truth  due  to  a  generally  vitiated  mental  and  physical  state, 
perhaps  inherited  from  a  feeble  ancestry.  Our  school  system  is  respon- 
sible for  a  good  deal  of  mischief,  but  not  for  meningiiis. 


DELIRIUM    GRAVE.  249 

exceptional.  In  one  case,  that  of  a  woman  without  a  pre- 
vious history,  whom  the  writer  saw  through  the  invitation  of 
the  city  physician,  Dr.  Hardy,  there  were  expansive  though 
vaguely  expressed  sexual  ideas;  she  recognized  every  male 
and  female  visitor  as  one  of  a  large  number  of  husbands. 

With  these  deliria  there  is  great  restlessness;  the  pa- 
tients make  aimless  efforts  to  escape  from  those  around 
them,  or  kick  and  strike  in  all  directions.  Sometimes 
rhythmical  motions  are  observed;  one  patient  under  the 
writer's  observation  continually  rolled  his  head  from  side 
to  side  day  and  night  (as  far  as  watched)  for  a  period  of 
three  days.  Grinding  of  the  teeth,  strabismus,  contraction 
of  the  pupils,  and  convulsive  movements  mark  the  transi- 
tion to  the  second  period  of  the  disease. 

There  is  in  many  cases  absolute  insomnia,  and  while  the 
general  nutrition  of  the  patient  suffers  appreciably,  the 
temperature  rises  to  over  100°  F.  and  may  reach  105° 
or  106°.  The  pulse  becomes-frequent  (130  in  one  case), 
soft,  compressible,  and  the  sphygmographic  trace  indicates 
extreme  cardiac  enfeeblement. 

The  second  period  of  the  disease  is  analogous  to  the 
post-maniacal  reaction  which  follows  the  outbreaks  of  sim- 
ple mania.  There  is  now  extreme  mental  and  physical  de- 
pression. The  patient  lies  apathetic,  mute,  collapsed;  has  a 
staring  or  startled  look;  does  not  recognize  what  is  going 
on  around  him;  or,  if  he  shows  an}?-  signs  of  mental  life,  these 
are  limited  to  incoherent  expressions  and  purposeless  and 
feeble  movements.  If  the  patient  does  not  die  in  this  con- 
dition he  passes  into  a  state  resembling,  as  Jessen  remarks, 
the  convalescence  from  typhus,  without  the  favorable  ter- 
mination of  the  latter.  It  was  this  feature  that  induced 
Luther  Bell  to  designate  the  disease  "  typhomania." 

The  severity  of  grave  delirium  is  specially  manifested  in 
certain  somatic  sequelae  of  the  excited  period.  The  hair 
falls  out,  the  skin  desquamates  and  is  cyanotic,  the  nails  ex- 
hibit an  atrophic  zone  corresponding  to  the  period  when 
the  disease  was  at  its  height,  the  spleen  is  slightly  enlarged, 
the  intestinal  tube  relaxed,  symmetrical  atrophy  of  certain 
muscular  groups  occurs,  and  the  reflexes,  which  at  first  were 
exaggerated,  become  diminished.  In  one  of  Jessen's  patients 
anaesthesia  became  so  extreme  that  he  gnawed  off  the  un- 
gual phalanx  of  one  of  his  fingers.    That  author  *  claims  that 

*  "  Ueber  die  klinische  Aeusserung  der  Reactions-Zustiinde  acuter  De- 
lirien.     Allg.  Zeitschrift  f.  Psychiatrie.       18S0-1. 


250  INSANITY. 

pemphigus-like  vesicles  appear  in  the  otherwise  apparently 
healthy  skin,  especiall}^  of  the  dorsal  faces  of  the  hands  and 
feet.  He  believes  this  to  be  a  comparatively  constant  sign;  it 
was  absent  in  tw^o  out  of  the  five  cases  observed  by  the  writer, 
while  phlegmons  and  spontaneous  gangrene  were  addition- 
ally noticed  in  one  of  the  cases  that  had  pemphigus.  Most 
of  these  conditions  are  due  to  the  vaso-motor  paresis  which 
marks  this  period. 

The  majority  of  the  patients  affected  with  grave  delirium 
die  in  the  delirious  period  after  an  illness  of  a  few  weeks; 
in  those  who  do  not  die  at  this  period  the  excitement  con- 
tinues unabated  for  four  or  five  weeks,  the  subsequent 
symptoms  of  stupor  increase,  and  the  history  closes  with  a 
fatal  coma.  Complete  recovery  never  occurs;  in  rare  instances 
the  patients  emerge  from  this  severe  disorder  with  a  slight 
mental  defect,  in  others  paretic  and  terminal  dementia  su- 
pervene. 

The  morbid  anatomy  of  this  disease  consists  in  an  intense 
hyperaemia  of  the  brain  and  meninges.  This  is  constantly 
found  in  patients  dying  in  the  excited  period  of  the  disorder; 
in  those  who  die  in  the  stuporous  period,  the  hyperaemia  is 
sometimes  obliterated  by  a  collateral  oedema;  but  in  all  the 
brain  appears  swollen,  the  cortical  ganglionic  elements  are 
granular  or  opaque,  stain  poorly,  and  their  perigangli- 
onic  spaces,  like  the  adventitial  lymph  sheaths,  are  literally 
crammed  with  the  formed  elements  of  the  blood.  In  the 
single  case  examined  pos^  mortem  by  the  writer  white  streaks 
were  found  on  either  side  of  the  larger  vessels  in  the  pia. 
Microscopic  examination  showed  that  they  were  due  to  an 
accumulation  of  leucocytes,  whose  preponderance  suggests 
an  inflammatory  nature  of  the  lesion  rather  than  the  condi- 
tion of  venous  engorgement  claimed  by  Krafft-Ebing.  A 
most  positive  sign  of  inflammation  was  found  in  the  case 
referred  to:  the  arterioles  were  surrounded  by  an  area 
staining  in  carmine  with  a  beautiful  pink  flush,  probably 
the  expression  of  a  molecular  infiltration,  while  layers  of 
newly-formed  fibrin  were  found  in  and  around  the  adven- 
titia. 

That  grave  delirium  is  the  result  of  a  vaso-motor  over- 
strain analogous  to  that  supposed  to  exist  in  paretic  demen- 
tia is  supported  by  the  etiology,  the  manner  of  origin,  and 
the  somatic  sequelae  of  this  disorder. 


CHRONIC   ALCOHOLIC   INSANITY.  25 1 

CHAPTER  XVI. 

Chronic  Alcoholic  Insanity. 

Alcoholic  excesses  play  an  important  role  in  the  produc- 
tion of  insanity.  Ordinarily  the  insanity  which  results 
from  such  excesses  belongs  to  the  groups  already  described. 
Thus  a  typical  acute  mania  or  melancholia  may  follow  a 
prolonged  debauch,  and  the  influence  of  chronic  alcoholism 
as  a  predisposing  factor  in  the  etiology  of  paretic  dementia 
and  delirium  grave  is  well  known.  There  are  also  certain 
mental  disturbances  of  a  character  peculiar  to  alcoholism, 
which  are  not  ordinarily  ranked  with  insanity,  but  which 
have  all  the  elements  of  the  psychoses — such  are  the  various 
states  of  drunkenness  itself  and  delirimn  tremens*  In  addi- 
tion there  are  various  forms  of  dementia  associated  with 
motor  disturbances,  which  depend  on  the  organic  changes 
produced  by  alcohol  in  the  brain  and  its  membranes,  and 
which  appertain  to  the  group  of  "dementia  from  organic 
disease." 

While  organic  changes  are  common  in  the  brains  of  sub- 
jects who  had  been  addicted  to  alcoholic  excesses,  and 
while  the  dementia  just  referred  to  is  with  its  accompany- 
ing motor  and  sensory  symptoms  present,  in  however  mild 
a  degree,  in  all  persons  suffering  from  advanced  alcoholism, 
not  all  forms  of  mental  disorder  found  in  such  subjects 
properly  belong  to  the  group  of  dementia  or  insanity  "  from 
organic  disease."  Just  as  epileptic  or  hysterical  insanity 
may  develop  as  an  epiphenomenon  on  the  epileptic  or  hys- 
terical neurosis,  so  a  special  form  of  alcoholic  insanity  may 
become  engrafted  on  the  alcoholic  neurosis.  It  has  distinct 
clinical  as  it  has  special  etiological  characters,  and  alone 
merits  the  designation  of  chronic  alcoholic  insanity. 

Before  proceeding  to  characterize  this  psychosis  it  is  well 
to  survey  the  extensive  pathological  territory  of  inebriety 
of  which  chronic  alcoholic  insanity  is  but  a  province.  The 
inebriate  generally  exhibits  moral  turpitude,  indifference  to 
his  interests  and  his  family,  morbid  irritability,  emotional 
depression,  to  overcome  which  the  libations  which  provoked 
it  are  repeated  and  prove  temporarily  remedial,  and  above 

*  A  detailed  description  of  these  conditions  is  here  omitted,  as  they 
are  usually  treated  of  in  extenso  in  works  on  general  neurology  and  clini- 
cal medicine. 


252  INSANITY. 

all,  a  marked  enfeeblement  of  the  will.  This  enfeeblement 
of  the  will  is  at  first  manifested  in  the  inability  of  the  ine- 
briate to  resist  the  temptation  to  drink.  Numerous  cases 
are  on  record  where  prosperous  business  men  and  capable 
men  of  letters,  feeling  this  abulia,  voluntarily  went  to  an 
asylum  for  inebriates,  and  within  its  walls  carried  on  their 
labors  as  well  as  before  they  had  formed  the  alcoholic 
habit.  But,  with  the  continuance  of  the  vice,  the  volition 
becomes  impaired  with  regard  to  other  matters  as  well,- and 
the  confirmed  and  deteriorating  inebriate  becomes  the  tool 
of  others.  He  attends  fairly  well  to  duties  of  a  routine 
character,  but  is  devoid  of  initiative,  or,  if  he  has  it,  is  in- 
consistent and  easily  diverted  from  his  purposes.  With 
this  there  is  noted  a  general  impairment  of  all  the  intellec- 
tual faculties,  the  memory  is  gravely  weakened,  and  the 
reasoning  powers  become  clogged. 

With  these  mental  symptoms  there  are  positive  signs  of 
the  disorder  of  a  somatic  character.  The  most  important 
and  constant  sign  is  the  alcoholic  tremor.  This  tremor  has 
the  peculiarity  that  it  decreases  under  the  influence  of  alco- 
holic beverages,  and  is  most  marked  when  the  patient  is 
perfectly  sober.  It  is  best  observable  in  the  hands,  tongue, 
and  lips.  Crampi  and  clonic  spasms  sometimes  occur  in 
the  extremities,  and  muscular  anenergy  is  frequently  com- 
plained of,  being  most  pronounced  in  the  extensors  of  the 
leg.  In  extreme  cases  an  actual  paraparesis,  or  even  para- 
plegia (Wilks),  probably  independent  of  a  structural  lesion, 
may  ensue. 

Hypercesthesias  and  anaesthesias  are  usually  among  the 
later  symptoms  of  chronic  alcoholism,  and  not  unfrequently 
has  the  diagnosis  of  incipient  paretic  dementia  of  the  as- 
cending or  spinal  type  been  made  on  the  strength  of  an 
anaesthesia  of  the  legs  and  feet,  coupled  with  the  lax  facial 
innervation,  enfeebled  memory,  hesitating  speech,  and  tre- 
mor of  chronic  alcoholism.  Occasionally,  lightning-like 
pains  and  analgesia  are  observed,  and  in  severe  cases  al- 
most any  form  of  sensory  disturbance  may  be  found,  from 
the  unilateral  haemi-anaethesia  observed  by  Magnan  to  the 
amblyopia  noted  by  Galezowski.  The  latter  condition 
may  even  be  associated  with  atrophy  of  the  optic  nerve.* 

*  In  the  case  of  a  gentleman  whose  will  was  made  the  subject  of  litiga- 
tion, and  who  undoubtedly  during  his  later  years  suffered  from  alcoholic 
dementia,  the  distinguished  ophthalmologist,  Knapp,  discovered  atrophy 
of  both  optic  nerves  some  years  before  marked  mental  impairment  had 
set  in. 


CHRONIC   ALCOHOLIC   INSANITY.  253 

Most  chronic  alcoholic  patients  are  anaemic  and  badly 
nourished,  for  there  is  usually  more  or  less  hepatic  and 
renal  trouble,  there  is  always  gastric  or  gastro-duodenal 
catarrh  and  general  degeneration  of  the  vascular  system. 
The  latter  manifests  itself  in  the  well-known  fatty  degen- 
eration of  the  cardiac  muscle,  and  in  ectasis  of  the  capillary 
and  atheroma  of  the  larger  blood-vessels. 

The  facial  appearance  and  attitude  of  the  chronic  inebriate 
are  characteristic.  There  is  a  general  laxity  of  muscular 
tone,  the  body  is  inclined  forward,  the  knees  bent,  the  eyes 
dull,  and  the  face  generally  defective  in  expression.  Most 
authorities  state  that  the  pupils  are  dilated,  but  the  writer's 
experience,  however  exceptional  it  may  be,  is  to  the  con- 
trary. 

The  above  may  be  looked  upon  as  the  prominent  signs  of 
a  constitutional  deterioration  of  a  neurotic  character;  and 
an  analogy  may  be  detected  between  the  progressive  mental 
enfeeblement  of  the  epileptic,  which  is  in  relation  to  the  fre- 
quency of  the  fits,  and  that  of  the  inebriate,  which  is  in  re- 
lation to  the  frequency  of  his  libations. 

On  this  chronic  alcoholic  constitution  as  a  background, 
the  well-characterized  psychosis  which  is  the  subject  of 
this  chapter  may  develop  just  as  epileptic  insanity  crops 
out  on  the  surface  of  the  epileptic  constitution.  It  is  noted 
that  positive  signs  of  mental  derangement  are  found  in  a 
great  many  inebriates  met  with  in  general  practice.  Hal- 
lucinations, chiefly  of  vision,  are  very  common  with  them, 
and  are  almost  without  exception  of  a  frightful  character; 
they  may  lead  the  patient  to  the  commission  of  brutal  crimes 
in  subjective  self-defence.  In  addition,  many  inebriates 
entertain,  if  not  delusions,  at  least  unfounded  suspicions  of 
marital  infidelity.  When  these  symptoms  become  constant 
and  prominent,  the  psychosis  first  described  by  Marcel,*  is 
before  us.  The  patient,  after  a  brief  prodromal  period 
marked  by  congestive  attacks  and  headache,  and  under  the 
influence  of  the  characteristic  hallucinations  of  alcoholism, 
becomes  the  subject  of  delusions  of  persecution,  and  very 
rarely  there  may  be  superadded  expansive  ones.  Krafft- 
Ebing  f  happily  draws  the  line  between  these  delusions, 
which   are  exclusively  determined    by  hallucinations,  and 

*  Marcel,  "  De  la  Folic  Causee  par  I'Abus  des  Boissons  Alcoholiques." 
Paris,  1847. 

f  Op.  cit.,  p.  1S6. 


254  INSANITY. 

the  persecutory  delusions  of  monomania,  which  are  some- 
times associated  with  hallucinations,  and  become  confirmed 
by,  but  are  never  provoked  by  them. 

The  persecutory  delusions  of  alcoholism  relate  to  the 
sexual  organs,  to  the  sexual  relations,  and  to  poisoning. 
This  fact  is  so  constant  a  one  that  the  combination  of  a  de- 
lusion of  mutilation  of  the  sexual  organs  with  the  delusion 
that  the  patient's  food  is  poisoned,  and  that  his  wife  is  un- 
faithful to  him,  may  be  considered  to  as  nearly  demonstrate 
the  existence  of  alcoholic  insanity  as  any  one  group  of 
S5^mptoms  in  mental  pathology  can  prove  anything.  With 
this  there  are  unpleasant  hallucinations.  The  patient,  who 
fears  that  he  is  about  to  be  castrated,  hears  people  com- 
menting on  the  fact  that  he  has  a  loathsome  venereal  affec- 
tion, or  that  his  penis  is  too  small  for  its  purposes,  and 
smells  seminal  discharges  which  are  drawn  from  him  at 
night.  Delirious  exacerbations  are  likely  to  occur  in  conse- 
quence of  the  patient's  morbid  fear,  and  in  brutal  fury  he 
may  hack  the  wife,  whom  he  suspects  of  infidelity,  to  pieces. 

There  is  this  peculiar  feature  about  the  delusions  of 
insane  inebriates,  that  their  acts  are  not  consistently  regu- 
lated by  their  delusions.*  Thus  one  patient  may  live  in 
comparative  tranquillity  with  a  wife  whom  he  suspects  of 
committing  adultery  in  the  boldest  manner  and  before  his 
face  night  after  night.  Another,  under  the  influence  of  the 
same  delusion,  may,  in  mortal  fear  of  being  poisoned  in  the 
delusive  paramour's  interest,  kill  his  wife  in  a  fit  of  blind 
fury.  Lennon,  the  New  York  murderer,  under  the  influ- 
ence of  similar  insane  ideas,  cut  up  his  wife  in  a  regular 
checker-board  pattern,  and  generally  the  crimes  of  these 
dangerous  lunatics  are  as  remarkable  for  their  cynical  bru- 
tality as  their  delusions  are  noted  for  obscenity. 

Besides  the  hallucinations  related  to  the  delusions  of 
sexual  mutilation,  impotence,  and  marital  infidelity,  there 
are  others  of  the  same  kind,  as  those  found  in  acute  alco- 
holic delirium:  the  patient  sees  mocking  faces,  snakes, 
insects,  dead  bodies,  paving  stones  precipitated  on  him, 
and  frequently  will  be  found  sustaining  a  dialogue  with 
some  absent  friend, f  and  stop  in  the  midst  of  conversation 

*  This  applies  to  the  fully-developed  disease  only. 

f  A  chronic  form  of  opium  insanity  which  is  in  every  respect  analogous 
to  chronic  alcoholic  insanity,  the  delusions  of  persecution  being  based  on 
visions  of  supernatural  instead  of  such  of  a  se.\ual  character,  has  been 
observed  in  three  instances  bv  the  writer.     A  marked  feature  of  one  of 


CHRONIC   ALCOHOLIC   INSANITY.  255 

with  persons  actually  present  to  answer  those  who  are 
miles  away  or  mouldering  in  their  graves. 

Sometimes  the  hallucinations  are  of  the  character  of  a 
photopsia;  one  patient  exhibited  at  Meynert's  clinic  saw 
lights  streaming  in  through  a  closed  door  one  night,  and 
heard  a  confused  noise  (tinnitus)  in  the  hall.  In  mortal 
dread  of  robbers  and  murderers  he  seized  a  hatchet  in  de- 
fence, fled  from  room  to  room,  and  finally  feeling  a  head 
on  a  sofa,  brained  its  possessor — his  own  father. 

The  periods  marked  by  anxious  hallucinations  are  usually 
but  imperfectly  retained  in  the  patient's  memory;  sometimes 
there  is  complete  amnesia,  and  one  fundamental  difference 
between  monomania  and  alcoholic  insanity  is  the  constancy 
•of  some  degree  of  enfeeblement  of.  the  memory  with  the 
latter  affection.  Occasionally  the  sufferer  from  alcoholic 
insanity  may  be  found  in  a  state  of  stupor;  but  this  differs 
from  the  superficially  similar  symptom  of  stuporous  in- 
sanity in  the  fact  that  the  patient  can  be  readily  aroused 
from  it  and  made  to  answer  questions. 

Chronic  alcoholic  insanity  is  more  frequent  in  countries 
where  spirits  are  consumed  than  where  malt  liquors  or 
wines  are  chiefly  used.  It  is  in  accordance  with  this  fact 
that  it  is  greatly  on  the  increase  in  countries  where  the 
lighter  liquors  are  being  supplanted  by  the  stronger  ones. 
This  has  been  noticed  to  be  the  case  in  Germany  and 
France;  regarding  the  latter  country,  Voisin  reports  the 
suggestive  fact  that  while  in  1856  only  99  patients  suffering 
from  the  various  forms  of  alcoholic  insanity  entered  the 
Bicetre,  in  i860  the  number  had  already  risen  to  207.  It 
must  not  be  believed  that  persons  indulging  in  malt  liquors 
and  wines  are  exempt  from  alcoholic  insanity.  While  this 
disorder  is  rarer  here,  quite  typical  cases  have  been  observed 
by  the  writer  in  persons  who  never  touched  a  drop  of  any 
■other  liquor. 

the  cases,  that  of  a  physician,  was  the  sustaining  of  dialogues  with 
absent  persons.  It  is  remarkable  that  every  form  of  alcoholic  mental 
derangement  is  imitated  by  the  opium  psychoses.  There  is  an  acute 
opium  delirium  analogous  to  delirium  tremens,  a  chronic  delusional  in- 
sanity due  to  opium  like  the  form  described  in  this  chapter,  and  in  one 
case,  that  of  another  physician,  first  treated  at  a  private  home  for  opium 
habitues,  the  writer  witnessed  an  attack  of  maniacal  furor  which  could  in 
no  respect  at  the  time  be  differentiated  from  the  exacerbations  of  paretic 
dementia.  In  the  quiet  period  there  were  noted  ataxic  and  paretic  symp- 
toms. The  patient  recovered  at  Bloomingdale.  This  case  is  analogous 
to  the  alcoholic  "pseudo-paralyses." 


256  INSANITY. 

The  prognosis  of  this  form  of  insanity  is  very  unfavor- 
able, as  there  is  a  pronounced  tendency  to  dementia.  Com- 
plete cures  are  rare,  and  if  the  affection  has  lasted  any 
length  of  time,  impossible.  The  higher  the  mental  status 
of  the  patient  the  better  are  his  chances,  but  asylum  treat- 
ment must  be  instituted  early  if  they  are  to  avail  him.  In 
one  case  the  writer  has  found  that  the  delusions  of  marital 
infidelity  disappeared  under  moral  treatment  and  a  reduc-- 
tion  of  alcoholic  beverages  at  home,  and  a  most  interesting 
case  of  complete  recovery  from  a  delirious  and  hallucina- 
tory variety  of  alcoholic  insanity  has  been  recently  reported 
by  Sander.* 


CHAPTER  XVII. 

Chronic  Hysterical  Insanity. 

Like  epileptic  and  alcoholic  insanity,  the  other  main 
types  of  this  division,  hysterical  insanity  is  found  to  be 
associated  with  a  fundamental  neurotic  character.  The 
patients  are  changeable,  emotional,  fretful,  careless,  and 
superficial  in  their  behavior  and  thoughts;  they  are  ex- 
tremely vain  and  egotistical,  and  desirous  of  notoriety  or 
sympathy,  or  both.  To  be  the  sufferer  from  an  equally 
interesting,  rare,  and  hopeless  nervous  disease  is  the  ambi- 
tion of  some;  to  be  considered  the  most  abused  woman  on 
earth  is  the  ambition  of  other  hysterical  patients.  If  the 
ordinary  means  fail  to  excite  attention  such  patients  will 
resort  to  extraordinary  ones  to  excite  sympathy.  The 
imitators  of  Louise  Lateau,  who  produced  artificial  stigma- 
tization,  and  the  hospital  patients  who  drove  hundreds  of 
needles  into  various  parts  of  their  bodies,  are  familiar  in- 
stances of  this  fact.  A  patient  of  the  writer's  suborned  her 
servants  and  nurses  to  give  false  testimony  to  the  visiting 
physician;  her  vigorous  fancy,  a  quality  shared  by  her 
sisters  in  misfortune,  enabling  her  to  sustain  their  asser- 
tions with  an  appearance  of  truthfulness  and  conviction 
which  at  the  time  was  real.  There  is  no  doubt  that  the 
"  tale  told  too  often"  is  finally  believed  in  by  the  patient, 

*  Psvchiatrisches  Centralblait,  Aug.  and  Sept.,  1877. 


CHRONIC    HYSTERICAL   INSANITY.  257 

and  that  the  potent  influence  of  the  mind  over  the  body 
must  be  looked  to,  to  explain  why  material  and  objective 
symptoms  appear  subsequent  to  the  pretence  being  made. 

A  patient  with  this  hysterical  character  may  develop 
psychoses  quite  analogous  to  those  found  in  epileptic  and 
alcoholic  patients.  Just  as  we  have  transitory  epileptic 
psychoses,  so  we  have  a  transitory  hysterical  psychosis 
manifesting  itself  in  deliria  of  fear.  Just  as  we  have  mani- 
acal and  melancholic  states  with  epilepsy  and  alcoholism, 
we  have  them  in  hysteria,  and  similarly  we  find  a  protracted 
psychosis  in  hysteria  analogous  to  the  alcoholic  disorder 
discussed  in  the  last  chapter. 

A  tendency  to  simulation  and  theatrical  behavior  is 
characteristic  of  these  various  forms  of  hysterical  disorder. 
They  are  particularly  marked  in  the  chronic  form  of  de- 
rangement about  to  be  briefly  considered. 

In  chronic  hysterical  insanity  an  intensification  of  the 
described  hysterical  character  is  the  most  constant  feature, 
a  silly  mendacity  is  frequently  added  and  develops  pari 
passu  with  advancing  deterioration.  Sexual  ideas  are  com- 
mon and  manifested  in  two  opposite  extremes:  either  there 
is  excessive  sexual  ardor,  which  may  be  so  intense  that  the 
patients  experience  the  orgasm  spontaneously,  or — and  this 
is  in  the  writer's  experience  far  more  common — there  is  an 
absolute  horror  of  anything  that  remotely  suggests  the 
sexual  act,  a  feeling  which  is  the  basis  of  a  hatred  of  the 
husband  frequently  exhibited  by  these  patients. 

Hallucinations  are  frequent,  and  usually  of  the  kind 
described  by  Wundt  as  fantastic  hallucinations.  They 
are  analogous  to  the  hallucinations  of  hypochondriacs, 
being  the  outcome  of  the  patient's  fancy  and  fears.  In  the 
case  of  one  patient,  who  was  an  excellent  artist,  visions  of 
countless  lovers  in  the  costumes  of  all  ages  and  peoples 
interspersed  with  horrible  visions  of  hell,  with  all  the  para- 
phernalia attributed  to  that  region  by  the  older  masters, 
were  the  most  prominent  symptoms.  In  some  cases  these 
visions  and  analogous  illusions  provoke  ecstatic  and  vision- 
ary states.  Krafft-Ebing  says:  "  On  this  basis  there  develop 
deliria  of  a  mystic  union  with  God  and  of  celestial  visions. 
The  patients  see  heaven  open,  indulge  in  enthusiastic 
preaching,  speak  in  strange  tongues,  prophesy,  etc."  This 
applies  to  the  episodial  deliria  of  monomania  with  a  hys- 
terical tinge,  and  not  to  hysterical  insanity  proper.  Here 
there  may  be  found  ecstatic  states,  but  they  resemble  rather 


258  INSANITY. 

the  deliria  of  hystero-epilepsy  than  the  visionary  deliria, 
and  where  such  ideas  and  acts  are  found  in  true  hysterical 
insanity  as  those  described  by  Krafft-Ebing  they  are  like 
those  of  the  hysterical  insane  epidemics  of  the  middle  ages, 
imitatory  phenomena. 

In  some  patients  obstinate  mutism  is  observed.  By  skil- 
ful cross  questioning  it  will  be  speedily  found  to  be  wilful; 
a  comical  series  of  questions  will  make  a  patient  who  has 
not  winced  under  the  wire  brush  smile;  the  suggestion  of 
a  vaginal  examination  will  make  her  blush;  and  a  skilfully 
provoked  petulant  answer  to  an  invidious  remark  will 
demonstrate  the  patient's  simulation. 

Illusional  transformations  of  sexual  sensations  are  a  fruit- 
ful cause  for  insane  ideas  in  hysterical  lunatics.  Most  of 
the  accusations  of  rape  made  against  physicians  and  den- 
tists, and  of  almost  daily  occurrence  in  asylums,  are  made 
by  insane  hysterical  patients. 

The  prognosis  of  this  form  of  insanity  is  unfavorable  as 
to  the  ultimate  termination  of  the  case.  Temporary  re- 
coveries are  noted  and  are  as  suddenly  established  as  many 
of  the  other  transformations  of  the  hysterical  state.  But  a 
recurrence  is  very  probable,  and  with  each  recurrence  de- 
terioration becomes  more  marked. 


CHAPTER   XVIII. 

Epileptic    Insanity. 

Most  of  our  psychiatrical  and  medico-legal  authors,  in 
discussing  the  medical  or  legal  relations  of  epilepsy  and 
epileptic  insanity,  limit  their  attention  to,  firstly,  the  con- 
dition called  epileptic  mania;  secondly,  to  epileptic  demen- 
tia, and,  thirdly,  to  the  peculiar  change  of  character  which 
many  epileptics  manifest. 

This  series  is,  however,  far  from  perfect,  and  fails  to  in- 
clude many  important  conditions  which  are  allied  to  and 
dependent  on  epilepsy,  and  which,  on  the  one  hand,  may 
require  special  medical  treatment,  and,  on  the  other  hand, 
merit  the  serious  attention  of  every  thorough  and  conscien- 
tious medical  jurist. 


EPILEPTIC   INSANITY.  259. 

It  is  an  opinion  quite  prevalent  with  many,  that  the 
epileptic,  unless  chronically  demented,  and  aside  from  the 
period  just  preceding  and  following  the  attack,  and  the  at- 
tack itself,  is  always  sane  from  a  medicah  and  competent 
and  responsible  from  a  medico-legal  point  of  view.  This 
view  is  held  by  many  general  practitioners  of  medicine,  and 
by  most  English  medico-legal  writers.  On  the  other  hand, 
there  are  those  who,  as  soon  as  they  find  the  slightest  in- 
dications of  epilepsy  in  the  person  under  investigation, 
instantly  jump  at  the  conclusion  that,  ergo,  that  subject 
cannot  be  of  sound  mind  or  responsible  for  any  transaction 
performed  by  him.  This  view,  as  the  reader  will  already 
have  anticipated,  has  had  its  origin  among  those  who  have 
been  or  are  frequently  called  by  the  defence  in  criminal 
cases,  where  insanity  is  the  last  resort  of  the  defendant. 
Both  views  constitute  utterly  erroneous  extremes,  but  they 
are  not  only  erroneous,  they  are  and  have  been  damaging 
to  the  cause  of  justice,  inasmuch  as  interested  or  possibly 
unscrupulous  medical  witnesses  have  been  able  to  fall  back 
on  such  views  enunciated  in  published  works,  in  support  of 
testimony  which  has  too  often  defeated  the  true  purpose  of 
the  law. 

Aside  from  epileptic  dementia,  a  mental  degeneration 
which  is  intimately  dependent  on  the  frequency  of  the  con- 
vulsive attacks,  and  which,  as  Esquirol  has  graphically  de- 
lineated, may  determine  stupor,  imbecility,  or  actual  idiocy, 
according  as  these  attacks  begin  later  or  earlier  in  life,  aside 
also  from  those  attacks  of  furious  madness,  or  purposeless 
automatism  ;r//d;^/«^  the  convulsive  attack,  and  which  may 
be  regarded  as  psychical  equivaloits  of  the  convulsion,  there 
are  forms  of  more  or  less  protracted  insanity  which  follow 
some  individual  epileptic  attack  or  break  out  in  the  interval, 
or  finally  extend  over  the  entire  interval,  which  are  to  be- 
strictly  distinguished  from  these  forms. 

It  was  the  observance  of  the  new  forms,  without  any  dif- 
ferentiation from  other  varieties,  that  led  Calmeil  to  say 
that  those  epileptics  not  yet  insane  are  very  irascible,  very 
impressionable,  inclined  to  false  interpretations,  and  to  ex- 
aggerate the  importance  of  petty  affairs.  This  description 
is  probably  based  on  cases  of  commencing  intervallary 
alienation,  and  it  would  be  erroneous  to  extend  it  to  most 
epileptics  living  without  asylums.  The  same  remarks  apply 
to  Baillarger's  statement,  that  the  characteristics  given  by 
Calmeil  often  precede  the  outbreak  of  complete  insanity.. 


260  INSANITY. 

Both  these  authors  seem  to  have  distinguished  but  imper- 
fectly between  actual  intervallary  insanity  and  the  ordinary 
change  of  character  discovered  in  the  interval.  Delasiauve 
has  also  doubtless  confounded  ordinary  epileptic  dementia 
with  post-epileptic  or  intervalrary  conditions  when  he  speaks 
of  patients  afflicted  with  "  stupidite  des  epileptiques"  as 
performing  automatic  acts,  looking  like  drunken  men,  etc. 

Falret  opened  the  way  for  a  rational  classification  with 
the  following  dictum:  "A  remarkable  phenomenon  which 
frequently  complicates  the  incomplete  attacks  of  epilepsy, 
or  the  interval  between  two  perfectly  developed  attacks, 
deserves  mention.  The  patient  seems  to  have  come  to 
himself;  he  enters  into  conversation  with  the  persons  who 
surround  him,  he  performs  acts  which  appear  to  be  regu- 
lated by  his  will,  and  seems,  in  one  word,  to  have  returned 
to  his  normal  state.  Then  the  epileptic  attack  recommences, 
and  as  soon  as  it  has  ceased  and  the  patient  has  recovered 
his  reason,  it  is  found,  to  one's  surprise,  that  he  has  not 
preserved  any  recollection  either  of  his  words  or  acts  which 
were  said  and  done  in  the  interval  of  the  two  attacks." 

Under  the  head  of  "  Petit  mal  intellectuel"   (not  to  be 


confounded  with  petit  mal  ordinarily  so  called),  the  same 
author  describes  a  condition  which  ma.y  continue  for  several 
hours  or  severST  days  alter  the  post-epileptic  stupor  has 
subsided,  in  which  the  patient  becomes  sullen,  deeply  de- 
jected, very  irritable,  and  feels  an  utter  inability  to  fix  his 
thoughts  or  to  control  his  will. 

Under  the  head  of  the  "  Grand  mal  intellectuel"  he  de- 
scribes an  analogous  but  longer  lasting  condition  coupled 
with  alternate  stupor  and  attacks  of  furious  excitement. 

As  Samt  correctly  remarks,  the  recognition  of  these 
forms  was  an  important  step  in  advance;  but  these  do  not 
exhaust  our  knowledge  of  the  possible  forms  of  post-epilep- 
tic insanity.  He  includes  both  X\\&  petit  mal  andi  grand  mal 
intellectuel  of  Falret  under  the  head  of  acute  post-epileptic 
insanity,  and  defines  the  latter  as  insanity  immediately  fol- 
lowing the  convulsive  paroxysm,  and  taking  an  acute 
course.     He  subdivides  this  acute  form  into: 

ist.  Simple  post-epileptic  stupor,  which  may  be  complicated 
with  dreamy  deliria,  or  with  illusional  or  hallucinatory  con- 
fusion and  verbigeration. 

2d.  Post- epileptic  jnorbid  conditions  of  fear  or  fright,  either 
simple  or  complicated  with  de'lire  raissonante  or  great  excite- 
ment.    The  latter  form  corresponds  to  Falret's  grand  mal 


EPILEPTIC   INSANITY.  261 

iiitclkctuel.  While  stupor  is  usually  present  in  this  form  it 
may  be  so  far  in  the  background  that  some  of  the  cases 
under  this  head  merit  being  characterized  as  cases  of  par- 
tial "frightful  "  post-epileptic  delirium. 

3d.  Post-epileptic  Maniacal  Moria. — This  form  is  rare,  and 
simulates  ordinary  acute  mania  to  such  an  extent  that  even 
the  expert  may  be  deceived.  It  is  only  the  irascible  char- 
acter of  the  mania  and  the  suspicious  manner  of  the  patient, 
and,  as  the  writer  believes,  the  treacherous  and  malicious 
character  of  his  violence,  which  enable  one  to  distinguish 
this  disorder  from  the  ordinary  attacks  of  the  acute  maniac, 
who,  under  appropriate  associations,  is  good-natured  and 
manageable,  aside  from  his  episodical  furor. 

Under  the  head  of  chronic  protracted  epileptic  insanity  he 
describes  many  cases  which  are  evidently  related  to  the 
post-epileptic  forms.  On  the  other  hand,  the  writer  has 
observed  some  cases  in  which  gradually  increasing  verbi- 
geration, delirium  of  a  religious  tinge,  or  maniacal  attacks 
with  or  without  intervals  of  stupor,  confusion,  and  automat- 
ism, preceded  the  outbreak  of  a  convulsion  or  its  equivalent. 
Just  as  the  forms  characterized  in  Samt's  classification  were 
designated  post-epileptic,  these  latter,  noticed  by  the  writer 
and  which  are  far  from  infrequent,  deserve  being  designated 
SiS  prodromal  or  pre-epileptic.  If  the  chronological  relation  of 
the  mental  disturbance  be  made  a  principle  of  classification, 
much  confusion  could  be  avoided  by  adopting  the  following: 

1.  The  epileptic  psychical  equivalent,  which  replaces 
the  convulsive  attack. 

2.  The  ACUTE  POST-EPILEPTIC  INSANITY,  wliich  almost  im- 
mediately follows  the  convulsive  attack  (including  the 
ordinary  post-convulsive  stupor  as  a  part  of  the  attack),  or 
similarly  succeeds  the  psychical  equivalent  of  such  con- 
vulsive attack.  Samt  states  that  he  has  observed  a  similar 
condition  in  connection  with  epileptiform  uraemic  convul- 
sions in  two  cases.* 

3.  The  PRE-EPILEPTIC  INSANITY,  whicli  prcccdcs  the  out- 
break of  a  convulsive  attack  or  its  equivalent,  and  increases 
up  to  the  moment  when  the  paroxysm  explodes. 

4.  The  purely  intervallary  epileptic  insanity,  which, 
neither  immediately  following  nor  preceding  a  paroxysm, 
occurs  in  the  interval  between  such.  It  is  possible  that  all 
such  cases  are,  after  all,  equivalents  of  imperfect  convulsions, 

*  Archiv.  f.  Psychiatric,  vi.,  p.    143. 


262  INSANITY. 

but  as  long  as  the  relation  cannot  be  clearly  established  it 
is  well  to  provide  a  category  for  the  reception  of  such 
doubtful  cases. 

It  is  possible  for  all  these  forms  to  occur  together,  and  in 
addition  there  is  very  apt  to  be  a  background  of  protracted 
epileptic  dementia  to  complicate  the  picture.  It  is  only 
when  epilepsy  is  recent  that  the  above  forms  are  found  in 
an  unmixed  state;  as  the  disease  progresses  we  are  very 
apt  to  find  that  the  post- epileptic  grand  wa/ i/if^/Zectue/ oi 
Falret  and  Samt  is  in  intimate  association  with  a  "  replac- 
ing" attack  of  violence.  Such  cases,  lasting  with  their 
correlated  stupor,  delirium,  and  confusion  for  entire  weeks, 
figure  as  "  epileptic  mania"  in  our  asylum  records. 

A  very  marked  case  of  the  grand  nial  intcllcctuci,  occur- 
ring in  a  recent  case  of  epilepsy,  interesting  because  of 
its  mal-recognition  and  subsequent  termination,  and  wliicli 
came  under  the  w-riter's  notice,  may  illustrate  some  prom- 
inent features  better  than  any  hypothetical  description. 
From  the  history  it  is  evident  that  pre-epileptic  insanity 
had  been  also  present. 

On  the  29th  of  December  the  writer  was  hurriedly  called, 
in  the  evening,  to  a  police  officer  wlio  was  stated  to  have 
"  fits"  at  his  residence.  On  arriving,  he  found  the  patient,  a 
powerfully  built  man,  standing  up  in  the  middle  of  the  room, 
his  relatives  holding  him.  The  patient  was  muttering 
unintelligibly,  but  recognized  that  a  stranger  had  come  in, 
though  supposing,  at  first,  that  the  latter  was  the  police 
surgeon  of  his  precinct,  with  whom  he  was  personally  well 
acquainted.  As  the  number  of  persons  surrounding  him, 
with  the  intention  of  restraining  him,  was  evidently  a 
source  of  excitement,  the  writer  ordered  all  but  a  few  to 
leave,  and,  slapping  him  on  the  shoulder,  told  him  every- 
thing would  be  "all  right"  if  he  would  sit  down.  He 
obeyed  in  a  dazed  and  bewildered  manner.  During  con- 
versation with  him  he  seemed  to  awaken  out  of  his  dreamy 
state  several  times  and  then  would  attempt  to  arise,  but 
could  be  easily  prevented  by  manual  restraint  and  would 
speedily  forget  his  intention  and  continue  the  interrupted 
conversation.  He  looked  suspiciously  and  furtively  around, 
and  seemed  to  be  suffering  from  a  general  oppression  and 
vague  fear.  His  pupils  were  moderately  dilated  and  the 
face  considerably  congested.  To  an  ordinary  beholder  he 
would,  for  considerable  periods,  give  the  impression  of  per- 
fect mental  equilibrium,  speaking  about  the  details  of  his 


EPILEPTIC   INSANITY.  263 

duty  and  the  personalities  of  higher  police  officers  in  a 
quiet,  deliberate,  and  apparently  intelligent  manner.  But 
he  seemed  to  enter  into  such  conversation  more  with  the 
idea  of  getting  rid  of  the  questioner,  and  of  the  restraint 
which  was  imposed  on  him  to  prevent  his  sallying  forth  to 
the  street.  He  was  dressed  in  a  morning  gown,  but  had 
thrown  his  police  coat  over  it  and  put  on  the  police  hat  and 
was  trying  the  different  doors,  from  which  the  writer  had 
had  the  keys  removed  after  locking  them.  He  then  endeav- 
ored to  go  out  of  the  window,  laboring  under  the  idea  that, 
as  he  would  be  dismissed  from  the  force  if  absent  continu- 
ally from  duty,  he  had  to  get  out  of  the  house  somehow.  It 
turned  out  that  all  this  time  his  diseased  condition  had 
been  recognized  at  headquarters,  and  he  had,  to  his  own 
knowledge,  been  excused  from  duty  several  days  previous. 
He  now  became  violent,  but  still  discriminated  between  the 
members  of  his  family,  whom  he  treated  both  with  physical 
violence  and  profanity,  and  the  physician,  whom  he  treated 
with  profanity  only.  When  his  wife  reminded  him  of  his 
discourtesy,  as  a  i-iise  to  divert  his  attention  from  his  ideas 

of  escape,  he  said,  "Oh, ,  the  doctor  knows  how  it  is 

himself."  One  of  the  children  whispered  to  the  other  to 
close  a  door  which  had  not  been  locked.  He  seemed  to 
hear  this  and  started  for  it.  The  writer  followed  and  closed 
with  him  to  prevent  his  passage.  In  attempting  to  over- 
come the  obstacle  which  was  made  to  his  passing  he  fell 
down  ;  then  he  said,  "Very  well,  I  knew  I  was  going  to  be 
murdered,"  and  could  not  get  up  till  the  writer  assisted  him. 
The  writer  turned  him  right  about  in  raising  him  and  the 
patient  continued  his  search  for  the  open  door,  but  went  in 
the  opposite  direction  and  returned  to  the  room  from  which 
he  had  started  without  noticing  it.  He  became  considera- 
bly excited  about  the  absence  of  his  shield  and  watch.  His 
wife  refused  to  say  anything  about  them  for  fear  that  he 
wanted  them  to  go  on  his  imaginary  duty  with.  He  be- 
came more  and  more  excited,  but  would  pass  to  other  top- 
ics, and  rested  in  the  chair  from  physical  weakness,  having 
fallen  to  the  ground  on  several  occasions.  When  his  wife 
told  him  that  she  had  his  watch  and  shield  he  seemed  sat- 
isfied, and  began  to  talk  as  if  he  were  in  the  station  house, 
spoke  to  the  writer  as  if  he  had  been  one  of  his  colleagues, 
and  related  incidents  and  arrests  in  a  wearisome,  mo- 
notonous way.  It  was  found  now  that  his  tongue  was 
tremulous  and  deviated  to  the  right  side,  the  facial  muscles 


264  INSANITY. 

of  the  left  side  were  more  firmly  contracted  than  the  right, 
but   there   was   no  noticeable   facial  deviation.     He   again 
wanted  to  go  out  with  his  hat  and  in  a  red  shirt,  and  had 
entirely  forgotten  the  fact  that  he  had  been  excused  from 
duty,  as  was  shown  by  conversation.    The  sedative  which  had 
been  ordered  now  arrived,  and  the  writer  readily  induced  him 
to  take  sixty  grains  of  bromide  of  sodium  with  five  grains  of 
chloral.     After    fifteen    minutes    he    seemed    a  little    more 
rational,  recognized  that  he  was  at  home,  and  was  induced 
to  go  to  bed,  after  it  was  proven  to  him  that  it  was  night  and 
not  noontime,  as  he  was  supposing.      His  previous  history 
was  as  follows  :  Half  an  hour  before  he  had  been  visited,  he 
had,  while  standing,  "suddenly  craned  round"  on  his  left 
side,  his  head  "  twisted  "  to  the  left,  his  eyes  "  rolling"  in  the 
same  direction,  and   he  was  "  perfectly  stiff,"  then  he   had 
violent  spasms,  and  "worked"  with  these  several  minutes; 
after  "a  short  spell"  he  got  up  and  acted  as  if  drunk,  con- 
tinuing to  manifest  similar  symptoms  to  those  which  are 
above  described,  but  had  one  attack  of  furious  violence  be- 
fore the  writer  came.     Two  days  previous  (the  27th)  he  had 
been  relieved  from  duty  and  sent  home,  under  some  pre- 
text, as  it  was  not  easy  to  reason  with  him.     That  he  had 
had  an  attack  of  mental  confusion  was  evident,  as  one  of 
his  brother  officers  subsequently  delivered   the  watch  and 
badge  to  his  wife.     He  was  "fiighty"  on  arriving  home,  and 
on  several  occasions  supposed  himself  at  the  police  station 
instead  of  at  his  house,  and  reproached  his  wife  with  being 
in  the  officers'  waiting  room,  and  counselled  her  to  go  home. 
On  previous  occasions  he  had  suffered  from  violent  neural- 
"•gia,  which  increased  in  severity  until  he  became  unconscious 
-gf  stupid,  atjgj^jynicn,  tne  neuralgia  cjisappearuTg.  he   be^ 
came  aelirjous!     This  had  occurred  within  the  last  five  years 
probably  a"3ozen  times,  but  the  only  pronounced  epileptic 
attack  which  he  had  had  was  the  one  following  which  the 
writer  saw  the  patient.     He  had  been  a  drinking  man,  and 
the  police  surgeon  had   made  the  diagnosis  "  alcoholism." 
During  the  night,  after  receiving  the  sedative,  the  patient 
slept  fairly,  but  awoke  twice,  and  on  one  occasion  went  into 
the    street    to   patrol,  and    was    brought  back   by  another 
policeman,  and    the  police  surgeon  again  took  charge    of 
him.     The  writer  saw  him  the  following  morning,  but  did 
not  treat  him,  as  his  regular  attendant  had  seen  him  shortly 
before.     The  patient  was  found  half  undressed,  eating  his 
breakfast,  his    face   extremely   turgid    and    congested,   his 


EPILEPTIC   INSANITY.  265 

mind  very  much  confused.  He  could  enter  into  ordinary 
conversation  for  a  few  moments  consecutively.  So  far  the 
writer's  observation  went.  Having  occasion  to  attend  an- 
other member  of  the  family,  he  learned  that  the  case  had 
terminated  in  a  very  abrupt  and  unexpected  manner.  The 
patient  went  out  in  full  uniform  at  ten  o'clock  of  the  second 
morning  following  and  patrolled  Fiftieth  and  Fifty-first 
streets,  without  exciting  any  attention,  his  behavior  not 
appearing  strange  at  all.  His  actual  "beat,"  however,  was 
Grand  and  Houston  streets,  three  miles  distant,  and  toward 
noon  he  went  to  Fifty-third  Street,  stating  it  to  be  Grand 
Street.  The  police  surgeon  had,  meanwhile,  ordered  him  to 
be  taken  to  a  certain  hospital.  This  was  accomplished  by 
deception,  a  neighbor  getting  him  to  arrest  her  little  boy, 
whom  he  took  to  the  hospital  in  triumph.  Once  there,  he 
was  placed  in  a  strait-jacket  and  breathed  his  last  in  this 
apparatus  that  same  evening.* 

This  was  a  case  in  which  pre- and  post-epileptic  insanity 
were  combined.  Other  cases  differ  only  in  exhibiting 
either  more  violence  or  some  predominant  delusion  or  hal- 
lucination. The  writer  may  refer,  as  an  example  of  pre- 
epileptic mental  disturbance,  to  the  case  of  a  little  girl 
described  in  an  earlier  journal  article,  who  manifested  an 
hallucination  which  gradually  increased  in  intensity  until 
the  convulsive  paroxysm  exploded.  In  this  instance  the 
hallucination  finally  became  intervallar)'-,  and  disappeared 
entirely  with  the  disappearance  of  the  epilepsy. 

The  following  case  illustrates  the  career  of  an  epileptic, 
marked  bv  numerous  characteristic  attacks  of  epileptic  in- 
sanity. Dating  from  his  thirty-ninth  year,  the  patient,  a 
prosperous  and  intelligent  business  man,  for  the  fifteen  years 
of  his  remaining  life^had  epileptic  convulsions  at  intervals 
of  from  one  week  to  several  monTRsT  His  business  asso- 
ciates observed  that  he  forgot  important  business  transac- 
tions, claimed  to  have  signed  vouchers  which  he  never  had 
■signed,  did  not  recollect  having  signed  others  which  he  had 
signed,  and  became  abstracted  and  dreamy,  on  one  occasion 
undressing  in  the  office.  Several  years  prior  to  his  death 
he  voluntarily  relinquished  the  responsible  position  he  had 
occupied  for  an  humbler  capacity  in  the  same  business. 
For  some  days  following  each  epileptic  attack  he  was  unable 

*  According  to  the  family,  the  marks  of  the  strait-jacket  were  plainly 
visible  on  his  body,  the  skin  being  chafed  and  cut  in  many  places. 


266  INSANITY. 

to  attend  to  his  business  affairs,  and  this  became  more  and 
more  noticeable  as  time  advanced.  On  one  occasion  he  had 
an  outbreak  of  furious  mania,  breaking  and  destroying^ 
everything  within  reach;  this  was  followed  by  a  state  of 
alternate  excitement  and  stupor,  he  yelled  that  he  was  being 
murdered,  that  people  were  setting  the  house  on  fire,  and  it 
required  the  force  of  several  men  to  hold  him  in  bed  ;  he, 
on  one  occasion,  got  out  on  the  staircase  in  his  night-shirt 
under  delusion  of  mortal  danger.  This  lasted  for  sev- 
eral days,  when  he  was  transported  to  the  lunatic  asy- 
lum. The  coach  driver  induced  him  to  enter  the  car- 
riage under  pretext  of  taking  him  out  for  a  drive.  When 
he  entered  the  asylum  he  was  indifferent  with  reference 
to  the  trick  played  upon  him.  This  indifference  is  a 
characteristic  feature  of  epileptic  insanity,  of  this  vari- 
ety. Later  he  was  alternately  clear  and  excited,  at  other 
times  in  a  drowsy  condition.  After  an  asylum  sojourn  of 
thirteen  days  he  left  the  institution  physically  improved, 
but  in  a  dazed  and  dreamy  state.  In  the  signature  to  a 
will,  made  a  few  days  later,  extraordinary  tremulousness 
and  irregularity  were  manifested.  The  lines  were  broken, 
one  "  s"  looked  like  an  "  e,"  the  scrawl  was  almost  illegible, 
and  the  name  "  George"  appeared  as  if  it  had  been  written 
Georger"  or  "Georgia."  His  ordinary  handwriting  was  a 
good,  clear,  average  business  hand,  and  he  had  been  in  the 
habit  of  signing  himself  "  Geo.,"  abbreviating  the  "  George." 
In  the  signature  there  was  a  gap  and  covered- up  break  be- 
tween the  first  three  letters  and  the  last  three,  as  if  the  dece- 
dent had  started  to  write  his  usual  abbreviation,  and  com- 
pleted the  full  name,  probably  on  suggestion.  Nineteen 
days  after  making  this  will  he  w'as  readmitted  to  the  asylum 
after  another  attack  of  violent  insanity  similar  to  the  one 
preceding  his  first  admission.  The  same  coachman  drove 
him  to  the  asylum  under  the  same  old  pretext  of  driving 
him  to  Coney  Island.  On  his  reception  in  the  asylum  he 
was  found  stupid,  presenting  marked  tremors,  and  for  sev- 
eral days  he  had  to  be  fed  with  the  stomach  pump,  he  re- 
fusing food  under  the  delusion  that  he  was  being  poisoned. 
His  tremor  continued,  gradually  increasing,  while  his  stu- 
por deepened  to  coma,  and  he  died  six  days  after  his  ad- 
mission. 

The  immediate  prognosis  of  epileptic  insanity  is  favor- 
able as  regards  the  more  acute  explosions.  The  protracted 
forms  are  sometimes  recovered  from,  but  here  mental  en- 


PERIODICAL   INSANITY.  26/ 

feeblement  is  more  likely  to  ensue  than  in  the  former.  The 
safety  of  society  demands  that  epileptic  subjects  should  be 
under  some  surveillance  after  being  discharged  from  an 
asylum,  for  the  epileptic  psychoses  may  break  out  with  great 
suddenness  and  lead  to  the  most  deplorable  results  at  any 
time. 


CHAPTER  XIX. 

Periodical  Insanity. 


Periodical  Ifisanify  is  characterized  by  the  recurrence  of  mental 
disorder  at  more  or  less  regular  intervals;  the  attacks  being  sepa- 
rated by  periods  during  which  the  patient  presents  a  state  of  ap- 
parent mental  soundness. 

Periodical  insanity  is  in  most  cases  what  Krafft-Ebing 
terms  a  degenerative  insanity,  being  the  manifestation  of  an 
hereditary  or  acquired  vice  of  the  constitution,  and  shares  the 
bad  prognosis  as  to  recovery  with  other  degenerative  disor- 
ders, such  as  monomania  and  epileptic  insanity.  Like  these 
forms  it  is,  in  the  vast  majority  of  the  cases,  hereditary,  and 
may  in  exceptional  instances  arise  after  an  injury  to  the  skull, 
or  from  prolonged  alcoholic  excesses.  Occasionally  the  out- 
breaks of  the  disease  are  coeval  with  certain  physiological 
periods  ;  this  is  notably  the  case  with  those  periodical  de- 
rangements of  females,  which  either  precede,  concur  with,  or 
follow  the  menstrual  period,  and  which  are  sometimes  des- 
ignated as  menstrual  insanity.  Inasmuch  as  the  menstrual 
condition  is  not  the  true  cause  of  this  insanity,  but  merely 
an  exciting  factor — the  real  cause  beingthe  hereditary  neuro- 
tic vice — menstrual  insanity  cannot  be  considered  a  separate 
clinical  form;  in  the  majority  of  cases  it  is  only  a  variety  of 
periodical  insanity  whose  periods  coincide  with  and  are  de- 
termined by  menstruation.  There  are  other  mental  disor- 
ders in  females  influencd  by  menstruation,  and  the  accepta- 
tion of  the  term  "menstrual  insanity"  would  hence  involve 
much  confusion. 

The  general  feature  in  which  all  the  periodical  insanities 
agree  is,  as  indicated  in  the  definition,  their  more  or  less 
regular  recurrence;  a  recurrence  as  marked  as,  and  in  many 
respects  analogous  to  the  recurrence  of  epileptic  fits.     Just 


268  INSANITY. 

as  the  epileptic  fits  are  merely  the  periodical  exacerbations 
of  a  deeper  constitutional  condition — the  epileptic  state;  so 
the  attacks  of  periodical  insanity  are  the  manifestations  of 
a  chronic  morbid  state  of  the  brain.  And-where  this  illness 
is  not  the  expression  of  an  hereditary  taint,  it  is  provoked  by 
such  causes  which,  like  traumatic  injuries  and  alcoholic  ex- 
cesses, may  imitate  the  evil  effects  of  heredity, and  artificially 
produce  a  disposition  to  nervous  and  mental  disease. 

The  regular  recurrences  of  the  morbid  explosions  in  peri- 
odical insanity  have  induced  not  only  the  ancients  to  sus- 
pect a  relation  between  them  and  the  influence  of  the  lunar 
changes,  but  within  the  year  a  German  alienist  (Koster) 
has  published  an  elaborate  treatise  to  prove  that  this  recur- 
rence is  in  periods  of  seven  days  or  in  multiple  days  of  seven, 
determined  by  the  apogee  and  hypogee  of  the  moon. 
There  may  be  a  dependence  of  this  kind,  but  the  writer  is 
unable  to  consider  it  a  direct  one,  but  rather  as  one  possibly 
determined  by  the  general  bodily  condition  at  such  periods. 
Barometric  and  seasonal  variations  appear  to  exercise  a 
much  more  palpable  influence  on  the  outbreaks  of  periodical 
insanity. 

The  theory  that  periodical  insanity  is  the  expression  of  a 
degenerative  taint  is  supported  first  by  statistics,  inasmuch 
as  the  majority  of  the  patients  have  a  bad  fam.ily  history; 
secondly,  by  the  frequency  with  which  somatic  signs  of  de- 
generation, cranial  anomalies,  and  other  evidences  of  dis- 
turbed development  are  found  in  them;  and  thirdly,  by  the 
fact  that  the  beginning  of  the  disorder  coincides  with  cer- 
tain physiological  periods,  such  as  puberty  and  the  climac- 
tenic,  while  its  exacerbations  often  follow  other  physiologi- 
cal periods,  such  as  menstruation;  this,  it  is  now  generally 
admitted,  is  a  feature  of  the  degenerative  psychoses. 

A  very  important  characteristic  of  periodical  insanity  is 
the  similarity  of  the  manifestations  in  the  different  at- 
tacks with  the  same  patient  for  long  periods.  Whatever 
form  one  given  attack  takes,  that  form  is  destined  to  charac- 
terize the  subsequent  attacks  for  many  years.  The  earlier 
attacks  are  sometimes  abortive  and  do  not  resemble  the 
later  ones;  and,  as  the  disorder  progresses,  the  attacks  be- 
come, as  a  rule,  more  severe  ;  but  for  any  period  extending 
over  a  number  of  years  the  attacks  are  so  similar,  that  the 
same  morbid  propensities,  the  same  imperative  conceptions 
and  impulses,  the  same  delusions,  hallucinations,  nay,  the 
same  insane  language,  occur  with  a  regularity  which  is  not 


PERIODICAL    INSANITY.  269 

the  least  Striking  feature  of  periodical  insanity.  This  is  not 
unlike  what  is  sometimes  observed  in  epilepsy,where  for  long 
periods  the  same  aura,  the  same  form  of  attack,  and  the 
same  post-epileptic  plienomena  are  found  with  each  explo- 
sion. It  is  not  without  some  bearing  on  this  similarity 
that  the  sufferers  from  periodical  insanity — at  least  in  the 
experience  of  the  writer — show  epilepsy  in  the  direct  and 
collateral  family  lines  more  often  than  other  insane  patients 
do. 

The  intervals  between  the  periodical  outbreaks  are  not 
alwa)'s  entirely  lucid,  but  rather  sub-lucid.  The  patients 
are  reasonable,  capable  of  attending  to  their  affairs,  and  a 
few  may  exhibit  nothing  abnormal  even  to  an  experienced 
alienist.  But  most  are  what  is  called  "nervous/'  the  fe- 
male patients  particularly  are  apt  to  be  markedly  hysteri- 
cal, and  a  morbid  irritability  is  quite  a  common  feature. 
In  advanced  periodical  insanity  the  patients  exhibit  a  per- 
manent change  of  character;  they  become  indifferent,  their 
emotions  are  blunted,  their  mental  energies  decrease,  and 
morbid  irascibility  becomes  more  prominent.  In  this  res- 
pect there  is  another  close  resemblance  between  the  epileptic 
neuroses  and  the  periodical  psychoses,  for  while  in  the  earlier 
periods  of  epilepsy  the  inter-epileptic  states  may  present 
nothing  noticeably  abnormal,  as  the  disease  progresses  an 
epileptic  change  of  character  usually  becomes  a  more  and 
more  marked  feature  of  these  intervals. 

With  the  exception  of  certain  cases  classed  as  circular  in- 
sanit}',  the  inception  and  termination  of  the  periodical  out- 
breaks are  more  abrupt  than  in  simple  mania  and  melan- 
cholia, which  these  outbreaks  may  otherwise  resemble.  In 
addition  the  deliria  if  present  are  apt  to  be  of  a  reasoning 
character,  while  moral  or  affective  perversion,  and  certain 
propensities  and  impulses  not  ordinarily  found  in  the  simple 
insanities,  serve  to  indicate  the  character  of  the  disorder. 
Aside  from  these  signs  it  is  only  the  history  of  the  case,  re- 
vealing the  periodical  recurrence  of  similar  attacks,  which 
serves  to  justify  a  diagnosis  that  the  disorder  is  probabl}^  a 
periodical  one. 

Periodical  Mania  generally  begins  abruptly,  though 
sometimes  it  is  inaugurated  by  a  brief  period  of  depression. 
More  frequently  signs  are  observed  which  Krafft-Ebing 
happily  compares  to  a  pre-epileptic  aura  :  the  heart  pal- 
pitates, while  vertigo  and  fiuxionary  head  symptoms  and 
neuralgic  signs  are  precursors  of  the  maniacal  explosion. 


270  INSANITY 

The  latter  is  marked  by  angry  rather  than  pleasant  excite- 
ment, by  moral  perversion  rather  than  by  sanguine  exal- 
tation, and  by  what  the  French  term  delirc  des  actes;  namely, 
a  tendency  to  continuously  perform  acts  impulsively,  such 
as  sexual  excesses,  indecent  assaults  and  exposures,  alter- 
nating with  thefts,  incendiarism,  and  errabund  *  tendencies, 
rather  than  by  the  ambitious,  teasing,  and  jocose  acts  of 
simple  mania.  In  females  the  tendency  to  cast  aspersions 
on  other  females  is  pronounced,  and  almost  characteristic. 
With  these  symptoms,  which  are  termed  deliria  of  acts, 
occasionally  hallucinations,  more  commonly  illusions,  and 
rarely  delusions,  may  be  added,  there  are  frequent  out- 
breaks of  angry  excitement,  and  these  are  of  a  violent  and 
dangerous  character.  They  are  sometimes  provoked  by 
the  alcoholic  excesses  to  which  periodical  maniacs  are  so 
likely  to  resort;  and  it  is  observed,  even  in  the  free  intervals 
of  periodical  mania,  that  alcoholic  beverages  are  not  borne 
well,  a  moderate  indulgence  leading  to  disproportionate 
disturbances  of  consciousness  and  of  the  will  power. 

Instances  are  recorded  where  a  single  morbid  propensity 
has  been  the  most  prominent  and  constant  feature  of  peri- 
odical mania.  Certain  sexual  aberrations  (p.  40)  are  par- 
ticularly apt  to  be  manifested  in  this  way  ;  as  in  the  case 
of  a  lady  observed  by  the  writer,  who  exhibited  violent  fits 
of  jealousy,  in  one  attack  leading  to  a  sanguinary  suicidal 
attempt  growing  out  of  a  sexual  perversion  of  a  platonic 
character.  Most  of  those  patients  described  as  kleptoma- 
niacs are  periodical  maniacs,  in  whom  the  propensity  to 
steal  predominates  over  the  ordinary  symptoms  of  mania. 

From  the  cases  of  periodical  mania  in  which  kleptomaniac 
and  other  morbid  impulses  predominate  over  exaltation,  the 
transition  to  those  forms  in  which  the  morbid  impulse  is 
the  sole  manifest  symptom  is  natural.  Almost  any  one  of 
the  known  forms  of  morbid  impulse  may  appear  in  periodi- 
cal phases,  but  this  is  particularly  the  case  with  the  morbid 
craving  for  drink,  which  seizes  on  its  subjects  at  certain  in- 
tervals with  such  intensity  that  the  ordinarily  quiet,  or- 
derly, refined,  and  sensitive  patient,  losing  all  sense  of  pro- 
priety and  shame,  gives  himself  up  to  unrestrained  and 
ruinous  debauchery.     This  distressing  condition  is  known 

Mauia  crrabunda  is  a  term  which  has  been  indiscriminately  applied  to 
periodical,  pubescent,  and  paretic  insanity  whenever  the  tendency  to 
roam  about  aimlessly  has  been  a  marked,  however  temporary,  feature  of 
the  insanity. 


PERIODICAL   INSANITY.  27 1 

^s  BIPSOMANIA.  It  is  to  be  distinguished  from  inebriety 
and  alcoholism;  for  the  inebriate  is  not  driven  to  his  ex- 
cesses so  suddenly  and  irresistibly,  nor  does  he  cease  them  as 
abruptly,  as  the  dipsomaniac.  In  the  inebriate  the  motive 
grows  out  of  appetite  and  habit ;  in  the  dipsomaniac  it  is 
a  blind  craving  which,  if  it  is  not  stilled  by  alcoholic  bever- 
ages, will  seek  some  other  outlet.  Often  these  patients  de- 
velop a  morbid  craving  for  certain  narcotics,  and  we  may 
thus  have  a  periodical  craving  for  opium  analogous  to  the 
periodical  craving  for  drink,  and  as  distinct  from  the  ordi- 
nary opium  habit  as  dipsomania  is  from  inebriety. 

As  a  consequence  of  his  blind  indulgence  in  drink  during 
his  diseased  periods  the  dipsomaniac  may  become  the  sub- 
ject of  acute  alcoholic  delirium,  or  of  chronic  alcoholism, 
though  the  latter  is  rare;  these  conditions  are  to  be  looked 
upon  as  results,  and  not  as  essential  features  of  dipsomania, 
which  is  to  be  defined  as  a  form  of  periodical  insanity  jnani- 
festing  itself  in  a  blind  craving  for  stimulant  and  narcotic  bever- 
ages. The  relationship  of  dipsomania  to  the  other  periodical 
neuroses  is  well  i  Ilustrated  by  the  instance — not  to  go  beyond 
cases  already  cited — of  the  lady  suffering  from  periodical 
exacerbations  of  sexual  perversion,  who  had  a  father  and 
two  brothers  dipsomaniacs,  and  one  sister  suffering  from 
periodical  neuralgias,  another  from  periodical  gloomy  spells. 

Periodical  Melanxholia  presents  no  distinguishing 
marks  from  ordinary  melancholia  in  its  individual  attacks. 
Its  periodicity  is  its  sole  criterion.  It  is  worthy  of  note 
that  periodical  melancholiacs  are  the  most  persistent,  cun- 
ning, and  successful  of  all  suicidal  lunatics. 

Periodical  insanity  does  not  always  manifest  itself  under 
the  guise  of  a  single  form  of  derangement.  There  is  a  sub- 
division known  as  Circular  Insanity  {cyclothymia)  which  is 
characterized  by  the  alternation  of  mania  and  melancholia  in  reg- 
ular recurring  cycles.  In  the  marked  cases,  for  example,  a 
profound  melancholia  is  followed  by  a  violent  mania,  this 
by  a  lucid  interval,  and  then  the  melancholia,  mania,  and 
lucid  interval  return  again  and  again,  in  the  same  order, 
comparably  to  the  succession  of  the  cold,  hot,  and  latent 
stages  of  an  attack  of  intermittent  fever.  In  some  cases 
there  is  no  free  interval,  the  mania  begins  when  the  melan- 
cholia ends,  and  the  latter  is  immediately  followed  by 
mania.  This  is  the  variety  to  which  Falret  first  applied  the 
term  folie  circtilaire ;  while  Baillarger  subsequently  dis- 
tinguished those  cases   in  which  a  more  or  less  perfect  and 


2/2  INSANITY. 

prolonged  lucid  interval  is  interpolated  under  the  designa- 
tion folic  a  double  forme. 

The  order  of  each  cycle  varies  in  different  patients  :  the 
mania  may  precede  the  melancholia  or  vice  versa.  Both 
may  be  of  a  mild  type,  and  both  may  be  very  severe;  or 
one  may  be  slight  and  the  other  intense.  A  furiburid  mani- 
acal attack  may  open  the  scene  and  be  followed  by  a  mild 
depression;  and  a  simple  exaltation  may  be  succeeded  by  a 
profound  melancholia,  with  anxious  delusions,  hallucina- 
tions, and  suicidal  inclinations.  On  the  other  hand,  a  mild 
melancholia,  not  exceeding  the  limits  of  a  moderate  degree 
of  inertia,  may  be  followed  by  violent  agitation  and  de- 
structiveness;  while  a  melancholia,  so  intense  as  to  approach 
the  degree  of  cataleptic  stupor,  may  give  way  to  a  sanguine 
exaltation  of  spirits,  scarcely  meriting  the  name  of  a  mania. 
It  is  such  cases  as  the  latter  which  constitute  connecting 
links  with  the  ordinary  forms  of  periodical  insanity  above 
considered. 

As  a  rule  the  mania  and  melancholia  correspond  to  each 
other  in  intensity.  Where  the  cycle  is  of  brief  duration, 
lasting  a  few  days  or  weeks,  both  are  apt  to  be  very  well 
marked;  where  it  is  of  a  duration  of  months  both  are  apt 
to  be  of  a  mild  type.  In  some  cases  the  patients  seem  to 
be  oscillating  between  extreme  moods,  which  show  an  alter- 
nation like  that  of  circular  insanity,  throughout  their  life- 
time; for  weeks  and  months  such  subjects  are  sanguine,  lo- 
quacious, energetic,  indulging  in  expensive  and  ambitious 
schemes,  and  then  during  the  next  few  weeks  or  months 
they  are  just  the  reverse;  they  seem  deprived  of  all  hope, 
are  taciturn,  inactive,  regret  their  extravagances,  and  undo 
what  they  have  undertaken.  Such  individuals  are  a  con- 
stant source  of  anxiety  to  their  relatives,  and  of  danger  to 
themselves.  It  requires  but  a  slight  circumstance  to  lead 
them  to  the  wasting  of  their  fortune,  to  other  extravagant 
acts,  or  to  develop  an  attack  of  furious  frenzy,  during  the 
exalted  period;  while  during  the  period  of  depression  they 
may  allow  a  flourishing  business,  undertaken  in  the  exalted 
mood,  to  go  to  ruin  from  inertia,  or  even  commit  suicide. 
It  is  in  cases  of  this  kind  that  we  are  least  likely  to  have  a 
lucid  interval.  Where  the  maniacal  and  melancholic  stages 
are  most  clearly  marked,  on  the  other  hand,  we  may  find  an 
equally  well  marked  period  of  unquestionable  mental  health 
separating  the  morbid  periods.  Instances  are  related  where 
a  patient   has    been    maniacal    one    day,   melancholic    the 


PERIODICAL   INSANITY.  273 

next,  lucid  the  day  thereafter,  then  maniacal  again,  and  so 
on.  The  writer  believes  such  cases  to  be  exceedingly  rare, 
the  shortest  cycle  he  has  seen  in  over  fifty  cases  lasted 
from  ten  to  twelve  days,  and  ordinarily  each  stage  covers 
from  a  week  to  a  few  months.  It  has  been  noted  that  in 
some  cases  the  alternation  corresponded  to  the  seasons:  the 
patients  being  melancholy  in  winter,  maniacal  in  spring, 
and  lucid  during  the  summer,  developing  melancholia 
again  in  the  fall. 

As  a  general  rule — not,  however,  without  numerous  ex- 
ceptions— the  shorter  the  cycle  the  more  intense  are  the 
symptoms,  and  the  better  also  are  the  prospects  of  the  case. 
Some  German  observers  have  found  that  the  patients  gain 
in  weight  during  the  maniacal,  to  lose  in  weight  in  the  mel- 
ancholic period;  but  this  is  not  a  constant  phenomenon. 

The  differential  diagnosis  of  circular  insanity  can  usually 
be  made  only  by  learning  the  history  of  the  case.  The  char- 
acteristic feature  which  serves  to  distinguish  it  from  other 
forms  of  insanity  is  the  alternation  of  the  opposed  conditions 
of  mania  and  melancholia,  and  this  alternation  can  be  glean- 
ed only  from  the  history,  or  detected  by  keeping  the  patient 
under  prolonged  observation.  During  the  maniacal  stage, 
as  a  rule,  it  is  impossible  to  discover  any  difference  from  an 
ordinary  case  of  simple  mania,  while  during  the  melancholic 
stage  it  is  equally  impossible  to  recognize  any  feature  not 
to  be  found  in  simple  melancholia. 

That  it  is  of  the  highest  importance  to  discriminate  be- 
tween an  ordinary  mania  or  melancholia  and  the  maniacal 
and  melancholic  phases  of  circular  insanity,  must  become 
evident  when  it  is  borne  in  mind  that  the  prognosis  in  the 
former  affections  is  in  the  highest  degree  favorable,  while 
in  circular  insanity  it  is  most  unfavorable.  In  some  cases, 
the  mania  and  melancholia  may  present  a  "reasoning" 
character,  and  thus  lead  to  the  suspicion  that  the  insanity 
is  circular  aside  from  the  confirmation  furnished  by  the 
history.  But  even  the  observation  of  an  entire  cycle  does 
not  establish  the  existence  of  this  form  of  insanity;  for  it  is 
well  known  that  a  simple  mania  may  be  preceded  by  de- 
pression, or  pass  to  recovery  through  a  stage  of  stupor,  and 
thus  resemble  such  a  cycle.  It  requires  the  demonstration 
of  several  cycles  to  make  the  diagnosis  of  circular  insanity 
complete. 

We  have  further  strong  reasons  to  suspect  the  existence 
of  this  disorder,  if  during  the  free  interval  the  patient  is 


274  INSANITY. 

noticed  to  be  morally  perverse.  As  in  periodical  insanities, 
generally,  the  lucid,  or  rather  sub-lucid,  intervals  of  circular 
insanity  are  often  marked  by  anomalies  of  character;  we 
find  these  patients  in  these  periods  of  this  disorder  to  in- 
trigue against  their  surroundings  merely  for  the  love  of 
intrigue  and  the  delight  which  they  experience  at  annoying 
others.  Neither  the  true  maniac  nor  the  melancholic  pa- 
tient ever  manifests  this.  The  former  delights  to  tease,  but 
usually  in  a  good  humored  way,  not  from  malicious  incli- 
nations ;  the  latter  prefers  to  be  let  alone. 

Occasionally  we  are  aided  in  our  diagnosis  by  narrowly 
watching  the  transition  between  the  mania  and  melancholia. 
Usually  this  transition  is  very  abrupt  and  complete;  the 
patient  goes  to  bed  melancholic  and  rises  maniacal;  it  is 
uncommon  for  the  maniacal  and  melancholic  symptoms  to 
balance  each  other,  so  as  to  constitute  a  para-lucid  tran- 
sition. 

Circular  insanity  generally  begins  at  or  about  the  age  of 
puberty,  is,  like  other  periodical  insanities,  more  frequent 
with  females  than  with  males,  is  intractable  to  treatment, 
and  while  it  does  not  ordinarily  lead  to  dementia,  some 
mental  deterioration  is  manifested  in  its  subjects  sooner  or 
later.  The  reported  cures  are  few,  and,  as  far  as  can  be 
gathered,  the  diagnosis  was  not  well  established  in  the  ma- 
jority of  these.  It  is  to  be  borne  in  mind  that  the  hysteri- 
cal psj'choses  as  well  as  malarial  neuroses  may  exhibit  an 
exquisite  circular  type  of  insanity.  The  writer  has  seen  this 
latter  phenomenon,  and  succeeded  in  controlling  the  dis- 
order with  quinine  and  calomel;  but  he  regards  such  a  case 
as  a  cured  malaria  which  manifested  itself  under  the  mask 
of  a  cyclical  insanity,  and  not  as  a  true  cyclothymia, 
which  is  the  expression  of  an  essentially  cerebral  and  deep- 
ly-rooted vaso-motor  neurosis. 

As  previously  stated  the  periodical  insanities  are  more 
frequent  in  females  than  in  males.  Among  other  causes 
which  account  for  this  difference  in  the  sexes  is  the  fact 
that  uterine  disorders  frequently  act  as  exciting  causes  of 
the  malady  in  predisposed  subjects  ;  this  may  account  for 
the  few  reported  cures  effected  by  gN'naecological  treat- 
ment. Of  2,297  male  pauper  patients,  the  author  found 
five  per  cent  suffering  from  periodical  and  its  sub-group 
circular  insanity.  Unfortunately  some  cases  of  so-called 
"  recurrent  mania"  were  included  in  the  computation,  so  that 
the  correct  figure  would  probably  be  nearer  four  per  cent. 


THE  STATES  OF  ARRESTED  DEVELOPMENT.   2/5 

CHAPTER  XX. 

The  States  of  Arrested  Development. 

By  many  the  conditions  known  as  idiocy,  imbecility,  and 
cretinism,  iiave  been  considered  to  occupy  a  position  sepa- 
rately from  insanity  proper.  To-day  we  know  that  the 
typical  psychoses  of  the  neuro-degenerative  series  may 
arise  on  the  basis  of  the  same  or  similar  developmental 
defects  as  those  which  are  so  characteristic  of  the  states  of 
arrested  and  perverted  development.  We  also  know  that 
this  fact  is  in  harmony  with  the  observed  "  transformation" 
of  the  ordinary  forms  of  hereditary  insanity  into  idiocy  and 
imbecility  in  the  course  of  hereditary  transmission;  and 
that  the  clinical  manifestations  of  the  latter  are  sometimes 
in  the  same  direction  as  those  of  insanity  proper.  For  all 
these  reasons  it  appears  inexpedient  to  make  a  sharp  sep- 
aration. 

It  is  customary  to  distinguish  three  grades  in  this  group. 
To  the  subject  deprived  of  all  higher  mental  power,  and 
who  is  unable  to  acquire  the  simplest  accomplishment,  the 
term  idiot  is  applied.  He  who  is  capable  of  acquiring 
simple  accomplishments,  but  unable  to  exercise  the  reason- 
ing power  beyond  the  extent  of  which  a  child  is  capable,  is 
designated  an  imbecile.  Finally,  there  is  a  large  class  of 
subjects  who  are  defective  as  to  judgment  and  in  whom 
this  defect  is  of  similar  origin  to,  though  not  as  intense  as, 
that  of  the  imbecile  and  idiot,  who  are  termed  feeble- 
minded. 

There  is  a  complete  series  of  transitions,  beginning  at  the 
lower  end  with  the  non-viable  anencephalous  monster  and 
passing  up  through  the  brain-monstrosity,  the  microcepha- 
lus,  the  idiot,  the  imbecile,  and  the  feeble-minded,  to  the 
normal  person.  This  transition  is  at  once  structural  and 
physiological. 

In  idiocy  there  is  usually,  in  addition  to  the  mental  defect, 
some  deficiency  in  the  peripheral  organs  or  their  functions. 
Many  idiots  are  deaf  or  mute  or  both,  some  are  blind,  and 
anaesthesia  as  well  as  anosmia  have  been  observed.  They 
learn  to  walk  late  or  not  at  all,  and  those  who  learn  to 
walk  have  a  shambling,  shuffling  gait,  which,  in  the  case  of 
the  microcephali,  is  said  by  Vogt  to  resemble  the  mode  of 


2/6  INSANITY. 

progression  of  the  anthropoid  apes  when  erect.  The  skel- 
eton is  usually  poorly  developed,  rachitis  is  common,  and 
the  somatic  functions  generally  are  imperfectly  performed; 
the  sexual  organs  particularly  are  found  to  be  rudimentary 
or  deformed. 

On  comparing  a  large  number  of  idiots  the  reflection 
forces  itself  on  the  observer  that  three  different  sets  of 
causes  of  arrested  development  are  active  in  producing  this 
condition.*  In  some  cases  we  find  that  one  of  the  parents 
of  the  idiot  has  an  abnormal  cranial  shape  or  premature 
ossification  of  the  sutures,  and  is  himself  or  herself  insane, 
epileptic,  hysterical,  or  feeble-minded.  Here  a  transmission 
and  intensification  of  the  ancestral  defect  is  to  be  assumed 
to  have  taken  place.  In  another  group  of  cases  we  find 
that  the  parents  were  originally  mentally  healthy,  but  that 
the  foetus  has  been  injured  or  has  acquired  some  constitu- 
tional vice,  such  as  syphilis  in  utero,  or  suffered  from  some 
brain  disorder  such  as  epilepsy,  eclampsia,  or  meningitis 
in  infancy.  Ireland  has  found  idiocy  resulting  from  brain 
disease  as  late  as  the  tenth  year.  In  the  third  group,  the 
smallest,  an  atavism,  that  is,  a  reversion  to  the  hypothetical 
ancestry  of  man,  has  been  suspected.  This  claim  of  scien- 
tists must  not  be  confounded  with  the  paradoxes  involving 
formally  similar  views  which  best  flourish  in  a  soil  untilled 
by  either  anatomical,  physiological,  pathological,  or  clinical 
observation.  It  is  a  fact  which  may  retain  some  degree  of 
that  same  historical  interest  which,  as  the  writer  has  stated, 
he  believes  will  cling  to  the  views  emanating  from  the 
laboratory  of  the  Utica  Asylum  (page  96),  that  a  recent 
course  of  demonstrations,  in  which  the  superintendent 
furnishing  them  got  over  the  entire  ground  of  insanity  in 
four  lectures,!  called  into  being  the  following  gem  of  com- 
bined psychiatry  and  zoology: 

*Dr.  Ireland  classifies  idiocy  as  followft  i.  Congenital.  2.  Micro- 
cephalic. 3.  Eclamptic.  4.  Epileptic.  5 .  Hydrocephalic.  6.  Paralytic. 
7.  Cretinic.  8.  Traumatic.  9.  Inflammatory.  10.  Due  to  depriva- 
tion of  the  senses.  The  microcephalic  idiots  are  always  congenital 
idiots,  while  paralytic  idiocy  is  really  mental  impairment  from  organic 
disease,  and,  as  the  subject  may  regain  mental  power,  should  not  be 
classified  with  idiocy.  The  last  group  is  not  a  real  idiocy,  any  more  than 
Casper  Hauser  was  an  idiot,  because  he  had  had  no  opportunity  to  learn. 

f  Clinical  Lecture  on  Dementia.  Idiocy,  and  Imbecility:  being  the  third 
of  a  course  of  four  lectures  upon  the  diagnosis  of  insanity.  Delivered  at 
the  New  York  City  Lunatic  Asylum,  Ward's  Island,  by  A.  E.  Macdonald, 
M.D.,  Medical  Superintendent. — A'.    Y.  Medical  Record,  Dec   20,  1879. 


THE   STATES   OF   ARRESTED   DEVELOPMENT.        2/7 

"  Here  is  a  negro  whose  feet  look  as  if  they  were  formed 
to  clutch  the  limb  of  a  tree,  and  it  does  not  require  a  great 
stretch  of  the  imagination  to  picture  his  ancestors,  in  no 
very  remote  generation,  jumping  from  limb  to  limb  of  some 
African  forest. 

"  And  with  this  return,  if  we  may  so  call  it,  toward  the 
appearance  and  form  of  other  animals,  there  is  an  equally 
perceptible  return  in  habit  and  action.  The  place  of  intel- 
lect seems  to  be  supplied  by  instinct,  and  by  it  the  behavior 
is  apparently  often  governed.  Thus  in  a  recorded  case,  an 
idiot  girl,  having,  while  alone  and  unattended,  given  birth 
to  a  child,  turned,  with  the  instinct  of  an  animal,  and 
gnawed  the  umbilical  cord.  Commonly  there  is  a  eoiisistent 
imitation  of  the  habits  of  some  one  animal,  and  its  posture  and 
movements  will  be  assumed,  and  its  habits  copied  even  to 
the  extent  of  showing  a  preference  for  whatever  forms  its 
natural  food.  I  have  read  of  a  case  where  a  woman  lived 
and  acted  like  a  sheep,  and  ate  grass;  and  I  know  of  a  case 
where  a  young  man  has  all  the  habits,  and  a  good  deal  of 
the  appearance,  of  a  well-conducted  horse.  He  harnesses 
himself  to  a  wagon  every  morning  and  trots  about  all  day, 
switching  a  tail  which  he  has  fabricated  out  of  old  rope, 
and  so  great  is  his  consistency  that  he  never  fails  to  shy  at 
a  wheelbarrow."  * 

Bucknill  mentions  cases  of  lunatics  (mostly  imbecile)  who 
believe  themselves  changed  to  toads,  to  oil-fiasks,  jump 
and  flutter  like  frogs  and  bats,  making  all  the  while  a  sound 
like  these  animals.  Esquirol  reports  that  in  a  certain  con- 
vent the  monks  believed  themselves  to  be  cats,  and  at  a 

*  The  writer  takes  it  for  granted  that  there  are  no  embellishments  in 
this  account,  although  he  has  frequently  seen  the  patient  and  never  ob- 
served the  last  symptom,  w^hich,  whether  it  existed  or  not,  had,  it  is 
needless  to  say,  no  bearing  on  the  question  of  a  reversion  to  the  equine 
instinct.  Huxley,  Darwin,  and  Haeckel  ought  doubtless  to  appreciate 
the  friendly  assistance  thus  afforded  them  by  Dr.  Macdonald;  but  they 
will  find  the  subject  of  the  descent  of  man  somewhat  complicated  by  his 
theory,  for  it  is,  to  say  the  least,  difficult  to  believe  the  ancestry  of  the 
human  being  to  have  started  pentadactylous,  become  artiodactyle  (sheep, 
according  to  him),  monodactyle  (horse,  same  authority),  and  then  penta- 
dactylous again!  As  to  the  negro,  "  Cuffy,"  whose  feet  are  the  strongest 
support  of  the  Doctor's  theory,  they  happen  to  be  the  seat  of  a  symmet- 
rical deformity  which  is  in  a  direction  altogether  the  opposite  of  a  simian 
reversion.  The  great  toes  are  long  and  stand  out  at  wide  angles  from  the 
line  of  the  next  toes,  and  are  /ess  apposable  than  in  the  normal  human 
foot,  while  they  should  be  more  so  than  in  the  latter  to  justify  the  flowery 
language  of  the  quotation.     The  italics  are  the  v/riter's. 


2/8  INSANITY. 

certain  hour  of  the  day  went  through  the  performances  of 
skipping  about  and  caterwauling.  The  writer  has  seen 
patients  who  acted  like  and  believed  themselves  to  be  steam 
engines,  windmills,  et  ccetera,  and,  if  we  were  to  apph'  the 
same  argumentation  running  through  the  above  extract, 
to  these  cases,  we  might  say,  it  requires  no  great  stretch  of 
the  imagination  to  picture  his  (the  patient's)  ancestor,  in  no 
very  remote  generation,  as  an  oil-flask,  as  a  cat  in  some 
New  York  back  yard,  as  a  frog  in  some  swamp  of  the  car- 
boniferous epoch,  as  a  toad  in  some  muddy  flat  of  New 
Jersey,  as  a  steam  engine  in  Birmingham,  as  a  windmill 
on  some  Netherland  dyke,  or,  finally,  as  a  bat  flitting 
through  the  darkness  of  some  ruined  castle  on  the  Rhine, 
and  so  on  ad  infinitum. 

The  presence  in  idiots  of  gyri  found  in  the  anthropoid 
apes  and  negro  (Zwickelwindung)  and  of  muscles  which  in 
normal  man  are  usually  rudimentary  or  absent,  are  facts  that 
lend  some  color  to  the  view  that  in  some  cases  idiocy  may 
be  due  to  an  atavism.  It  is  to  be  insisted  on,  however,  that 
no  atavism  can  ever  imitate  or  reproduce  the  links  of  pro- 
gressive development.  Just  as  in  normal  development  the 
branchial  slits,  the  coloboma  oculi,  the  caudal  appendage, 
the  cloaca,  the  supernumerary  digital  rays,  the  thirteenth 
and  fourteenth  ribs,  the  Wolffian  body,  and  the  carnivora- 
like  claws  and  foot-pads  of  the  human  embryo  imitate  cer- 
tain structural  peculiarities  of  the  lower  creation  without 
being  exactly  like  them;  so  the  cerebral  and  skeletal  pe- 
culiarities of  atavistic  idiots  resemble  without  accurately 
reproducing  those  of  the  ape. 

It  is  sometimes  observed  that  the  appearance  of  idiots 
strikingly  suggests  a  reversion  to  or  imitation  of  certain 
ethnic  types.  In  some  cases  Caucasian  idiots  reproduce 
to  a  perfectly  wonderful  degree  the  Mongolian  features. 
It  is  to  cases  of  this  kind  that  Dr.  Mitchell  and  Dr.  Fraser 
give  the  name  of  Kalmuck  idiocy.  The  writer  has  observed 
the  same  resemblance  in  an  imbecile  murderer,  and  in  the 
three  dwarfed  idiotic  brothers  who  are  now  on  exhibition 
in  a  "  Museum"  of  this  city,  and  whose  photographs  ac- 
company a  paper  on  the  subject,  published  by  Hammond 
in  his  "  Neurological  Contributions."  The  thick  lips,  large 
fleshy  tongue,  bullet-shaped  occiput,  curly  hair,  and  dark 
skin  of  the  negro  are  found  in  another  group,  and  Dr.  Down, 
who   first   called   attention   to   the   ethnic   types  in  idiocy^ 


THE  STATES  OF  ARRESTED  DEVELOPMENT.   279 

claims  that  not  only  the  Mongolian  and  Ethiopian  but  also 
the  Malay  type  may  be  found  in  Caucasian  idiots. 

It  is  in  idiots  of  the  "atavistic"  group  that  we  sometimes 
find  the  so-called  instinctive  faculties  tolerably  well  de- 
veloped, in  contrast  with  the  majority  of  those  suffering 
from  arrested  brain  development.  Usually,  however,  and 
contrary  to  the  current  belief,  the  lower  faculties  of  the 
mind  suffer  as  well  as  the  reasoning  powers,  and  this  is  in 
harmony  with  the  fact,  that  it  is  not  alone  the  higher  cen- 
tres that  suffer  with  defective  cerebral  development,  but  that 
the  thalami,  the  cerebellum,  and  the  cerebral  isthmus  of 
idiots  are  often  found  to  be  defective,  or  asymmetrical,  or 
both. 

It  is  probably  due  to  a  deficient  trophic  innervation  that 
idiots  so  frequently  suffer  from  cataract,  and  it  must  be 
recollected  in  this  connection  that  the  morbid  anatomy  of 
idiocy  and  imbecility  is  not  necessarily  limited  to  anatomi- 
cal defects,  but  tliat  progressive  structural  lesions  may 
develop  in  the  idiot's  or  imbecile's  brain.* 

While  the  sexual  function  is  usually  in  abeyance  in  idiots, 
there  are  cases  where  it  has  been  fairly  well  carried  on. 
Thus,  John  Rouse,  the  celebrated  microcephalous  idiot  on 
Randall's  Island,  is  known  to  have  had  sexual  relations 
with  low  women,  and  to  have  manifested  at  times  a  strong 
sexual  appetite;  and  several  instances  are  reported  where 
idiotic  girls  have  been  impregnated  and  delivered  of  chil- 
dren.f  The  history  of  the  confinements  of  idiotic  mothers 
illustrates  very  finely  the  erroneous  nature  of  the  popular 
view  that  the  idiot  is  necessarily  a  creature  of  strong  or 
perfect  instincts.  While  idiots  have  been  confined  and 
have  like  animals  lacerated  the  umbilical  cord  with  their 
teeth — an  admirable  provision  against  haemorrhage — and 
evidently  have  done  so  without  reflection  and  judgment, 
there  are  many  more  cases  on  record  where  both  reason 
and  instinct  seemed  to  be  altogether  in  abeyance.  Cham- 
beyron,  in  his  translation  of  Hoffbauer's  treatise  on  the 
medical  jurisprudence  of   insanity,  relates  the  case  of  an 

*Thus  Luys  {VEncephale,  Mai,  1881)  has  found  that  the  cortical  nerve 
cells  in  idiots  undergo  necrobiotic  changes,  and  Bruckner  {Archiv  f. 
Psychiatrie,  xiii.  i)  and  Bonneville  {Archives  de  Neurologie,  i,  p.  81)  have 
found  a  peculiar  "tuberous  sclerosis"  which  involved  the  cortex  in 
numerous  patches  in  two  cases. 

f  Unfortunately  the  history  of  the  children  has  not  been  satisfactorily 
traced. 


28o  INSANITY. 

idiot  whom  he  confined,  whose  vocabulary  was  limited  to 
the  sounds  "  ta-ta,"  and  who,  although  her  pelvis  was  well 
formed  and  the  presentation  a  good  one,  did  not  know 
enough  to  assist  the  expelling  power  of  the  uterus  with  her 
abdominal  muscles;  and  could  not  be  made  to  imitate  the 
movements  necessary,  although  made  before  her  by  other 
women.  She  simply  fingered  around  her  genitals  in  a 
purposeless  way,  and  after  the  child  was  born  she  took  no 
notice  of  it  whatever. 

The  imitative  tendencies  are  often  very  strong  in  idiots; 
in  imbeciles  they  may  be  utilized  to  make  good  artisans  of 
the  subjects;  in  idiocy  they  lead  to  destructive  and  tragical 
results  owing  to  the  utter  absence  of  any  higher  intelli- 
gence. Thus  some  twelve  years  ago  an  idiotic  boy  in 
Maine  killed  the  child  of  the  people  who  cared  for  him, 
hung  it  up,  and  dressed  it  exactly  as  he  had  seen  a  sheep 
dressed;  and  another,  referred  to  by  Gall,  butchered  a  man 
precisely  as  he  had  seen  a  hog  butchered. 

In  the  lowest  form  of  idiocy  speech  may  be  altogether 
absent,  or  limited  to  a  few  inarticulate  sounds,  in  others  a 
few  words  and  short  sentences  may  be  acquired.  While 
some  idiots  show  no  spontaneity  whatever,  and  have  to  be 
fed  like  infants,  others  are  ravenous  eaters.  A  few  exhibit 
explosions  of  furious  and  blind  violence  and  morbid  im- 
pulses. 

Idiots  rarely  reach  maturity. 

The  study  of  imbecility  and  its  lesser  degree,  feeble-mind- 
edness,  is  of  much  greater  practical  importance  to  the 
alienist  than  that  of  idiocy.  It  is  a  popular  and  erroneous 
belief  that  an  imbecile  is  one  entirely  void  of  ideation.  It 
thus  happens  that  imbecility  is  often  overlooked,  when  the 
subject  is  in  the  lower  walks  of  life,  and  that,  as  Georget 
very  happily  observes,  "  it  is  above  all  in  the  inferior  walks 
of  society,  where  the  individuals  need  but  little  intelligence 
to  carry  out  simple  labors,  and  to  fulfil  limited  social  obli- 
gations, that  only  those  are  considered  imbecile  who  are 
not  even  able  to  lead  a  horse  or  to  watch  a  herd."  A  degree 
of  imbecility  which  would  scarcely  be  observable  to  the 
laity  in  a  hod-carrier,  would  be  very  manifest  in  a  school- 
boy and  academical  scholar.  The  writer  has  known  imbe- 
ciles, who  had  to  be  removed  from  school  because  unable  to 
keep  up  in  their  studies  with  children  many  years  their 
juniors,  to  become  successful  mechanics  and  good  copyists. 
Even  in  asylums  there  are  many  imbecile  inmates  who  are 


THE   STATES   OF  ARRESTED    DEVELOPMENT.        28 1 

employed  in  the  garden,  the  kitchen,  as  aids  in  the  hospital 
wards,  and  who  are  occasionally  more  methodical  and  re- 
liable in  their  limited  sphere  of  action  than  the  attendants 
placed  over  them  are  in  theirs.  The  imitative  tendencies 
which  are  more  common  here  than  in  idiocy  are  often  uti- 
lizable,  as  has  been  previously  observed,  in  making  of  the 
imbecile  not  only  a  good,  but  sometimes  a  very  skillful 
mechanic.  His  mechanical  skill  is  mainly  shown  in  the  di- 
rection of  imitation  and  reproduction,  and  but  rarely  in  a 
new  or  untrodden  field.  It  is  similar  with  other  mental 
processes.  Imbeciles  sometimes  have  an  excellent  memory 
for  simple  facts.  There  are  instances  on  record  where  im- 
beciles have  known  the  dates  of  the  birth,  marriage,  and 
death  of  every  person  dying  in  a  certain  community  for 
thirty  years,  or  the  time  of  departure  of  every  railroad 
train  that  had  left  a  certain  station  in  the  same  time.  But 
the  imbecile  is  unable  to  form  or  to  unravel  those  complex 
combinations  of  which  simple  impressions  are  the  compo- 
nent units.  The  mental  state  of  the  imbecile  has  been  very 
well  expressed  by  the  statement  that  those  mental  co-ordi- 
nations acquired  in  the  course  of  a  higher  civilization  have 
not  been  formed  in  him.     (See  page  loi,  foot-note.) 

While  the  imbecile  is  defective  as  to  his  reasoning  ca- 
pacity, his  emotional  state  may  present  every  analogy  to 
that  of  healthy  persons,  or  approximate  that  of  other  forms 
of  insanity.  Thus,  there  are  imbeciles  who  are  mild,  affec- 
tionate, good-natured,  and  even  philanthi opical ;  on  the 
other  hand,  there  are  imbeciles  who  are  treacherous,  suspi- 
cious, and  cruel.  Moral  defect  is  a  prominent  feature  of 
some  cases,  and  this  condition  may  be  the  chief  manifesta- 
tion of  mental  deficiency.  There  are  subjects  whose  rea- 
soning powers  are  fair,  whose  memory  is  excellent,  who  are 
perhaps,  accomplished  in  the  arts,  but  in  whom  the  moral 
sense  is  either  deficient  or  entirely  absent.  The  term  moral 
itisa?7ity  of  authors  should  be  limited  to  this  class  of  sub- 
jects, and  a  much  better  term  to  use  would,  in  the  writer's 
opinion,  be  moral  imbecility. 

Morbid  projects,  imperative  impulses,  and  morbid  ego- 
tism are  found  in  some  imbeciles,  and  in  such  cases  it  may 
be  difficult  to  decide  whether  they  appertain  to  the  group 
of  imbecility  or  of  original  monomania.  There  are  numer- 
ous other  points  in  which  imbecility  proper,  and  mono- 
mania, which  may  in  some  respects  be  considered  a  "par- 
tial imbecility,"  approach  each  other.    Several  of  these  have 


282  INSANITY. 

been  referred  to  in  the  chapter  on  the  somatic  signs  of  the 
predisposition  to  insanity  (page  88);  a  most  remarkable  one 
is  the  fact  that  one-sided  talent,  other  than  that  resulting 
from  the  imitative  tendency  referred  to,  is  sometimes 
found  in  imbecility,  just  as  a  similar  condition  is  found  in 
monomania.  Thus  imbeciles  have  been  known  to  manifest 
a  marked  aptitude  for  the  arts,  such  as  music.  This  latter 
has  been  especially  noted  by  Meyer  in  imbeciles  present- 
ing the  crania  progenia. 

The  one-sided  development  of  special  faculties,  and  the 
positive  signs  of  alienation,  such  as  moral  perversion  and 
anomalies  of  character,  are  characteristic  rather  of  the  hered- 
itary than  the  acquired  cases  of  imbecility.* 

Both  imbecility  and  idiocy  are  sometimes  marked  by 
other  disturbances  of  the  nervous  functions  than  those  com- 
prised in  the  mind.  Epilepsy  is  a  frequent  accompaniment, 
and  may  be  very  bizarre  in  those  cases  where  it  is  the  re- 
sult of  a  cerebral  defect,  involving  a  few  muscles  or  one  ex- 
tremity, or  being  associated  with  a  choreiform  aura. 

Both  idiocy  and  imbecility  may  be  dependent  on  early 
epilepsy,  but  more  frequently  the  mental  defect  and  the 
convulsions  are  collateral  phenomena,  both  depending  on 
defective  development. 

Spastic  symptoms,  contractures,  strabismus,  peculiar 
speech  defects — manifested  in  the  inability  to  pronounce 
certain  consonants — and  stuttering  are  also  noted,  and  it  is 
the  occasional  presence  of  all  these  signs  in  hereditary 
monomania  (Originare  Verriicktheit)  that  gives  additional 
force  to  the  view  that  there  is  no  absolute  line  of  demarca- 
tion to  be  drawn  between  the  various  forms  of  the  degen- 
erative nervous  states. 

The  course  of  idiocy  and  imbecility  is  usually  unmarked 
by  any  changes,  and  these  conditions  are  therefore,  as 
a  rule,  stable  ;  occasionally  progressive  deterioration  is 
caused    by    epileptic    fits,    and   where    hydrocephalus  and 

*  Krafft-Ebing  makes  the  sweeping  assertion  that  the  one-sided  de- 
velopment of  special  faculties  is  never  found  in  acquired  imbecility.  It 
is  more  correct  to  speak  of  their  presence  as  a  characteristic  feature,  for 
exceptions  undoubtedly  exist ;  just  as  there  are  well-established  cases 
where  acquired  imbecility  has  chiefly  manifested  itself  in  the  moral 
sphere,  although  the  rule  is  that  moral  imbecility  is  more  frequent  in  the 

transmitted  forms.     In  the  case  of  Louisa  W e,  exhibited  before  the 

N.  Y.  Neurological  Society  last  December,  whose  imbecility  developed 
with  a  scarlatina,  moral  perversion  was  the  most  prominent  of  the  con- 
stant symptoms.     An  analogous  case  has  been  reported  by  Hughes. 


THE  STATES  OF  ARRESTED  DEVELOPMENT.   283 

meningitis  are  the  causes,  exacerbation  of  tiie  morbid  proc- 
ess may  lead  to  further  impairment  of  the  mind.  In  the 
latter  cases  the  cerebral  disorder  may  directly  lead  to  a  fatal 
termination.  Unless  syphilis  is  the  cause,  and  rarely  then, 
therapeutic   measures   are  incapable   of  doing  any  good, 

Fig.    io. 


-"^ 


r.v\-v  -.  - 1.  •>.  .-^ .  r.v^•^  ■  -  ^.  ••'•.-  • 

^-Xi'i,  ■.*.'.'••  •  ';:•'  ■■■c^  J-V-.M-V',  /.'■*•■  •  'f:--„-:f:- 

k  *  '...  -^  •'.  k         •'  :-  ^  •'. 

t 

and  the  prognosis,  as  far  as  the  development  of  the  mind  is 
concerned,  is  as  bad  as  it  can  well  be.  As  to  the  life  of  the 
patient  it  is  usually  shortened  by  intercurrent  diseases,  to 
which  the  feeble  body  of  the  imbecile,  like  that  of  the  idiot, 
readily  succumbs  ;  in  a  few  cases  the  bodily  health  may  be 
good,  and  the  subject  reach  old  age. 

A  peculiar  form  of  idiocy  is  found  associated  with  a  dis- 
order endemic  to  certain  mountainous  districts,  particularly 


284 


INSANITY. 


the  Alps,  Pyrenees,  and  Cordilleras.  This  is  a  constitu- 
tional deterioration  manifesting  itself  in  pronounced  anom- 
alies of  the  entire  physique.  There  is  usually  great  physi- 
cal deformit}^  the  head  appears  swollen,  the  features  are 
coarse,  the  nose  depressed  at  the  root,  the  belly  is  distended, 
and  the  cheeks  puffy  owing  to  a  hypertrophy  of  the  skin  and 
subcutaneous  cellular  tissue.  With  this  the  thyroid  gland 
is  commonly  enlarged.    A  more  disgusting  object  than  such 

Fig.    II. 


a  cretin,  with  his  childish  expression,  yet  old-looking  teat- 
ures,  the  deformed  body  and  the  enormous  lobulated  goi- 
trous appendage,  cannot  well  be  imagined.  True  cretin- 
ism has  not  yet  been  observed  in  North  America,  but  a  simi- 
lar condition  has  been  noticed  by  the  writer  in  three 
children  of  parents  living  in  our  swamps,  and  is  probably 
the  expression  of  a  paludal  cachexia. 

The  mental  phenomena  of  cretinic  idiocy  are  like  those 
of  ordinary  idiocy.  Similar  physical  defects  are  found,  in 
addition  to  those  which  are  characteristic  of  the  cretinic 
state  itself.  Thus,  cretins,  like  idiots,  are  liable  to  epileptic 
convulsions,  their  dentition  is  imperfect  or  retarded,  and 


THE  STATES  OF  ARRESTED  DEVELOPMENT. 


285 


the  teeth  decay  early,  and  in  extreme  cases  walking  may  be 
impossible. 

To  enumerate  all  the  interesting  and  significant  anatomi- 
cal conditions,  particularly  of  the  skull  and  brain,  found  in 
the  various  forms  of  idiocy  and  imbecility,  would  require  a 
special  volume.  In  addition  to  those  anomalies  mentioned 
in  general  terms  in  the  first  part  of  this  work,  the  following, 
found  by  the  writer,  may  be  briefly  referred  to:  In  two 
imbeciles,  one  of  whom  had  a  hypertrophy  of  the  brain, 
that  organ  presenting  one  of  the  heaviest  weights  on  record 
(68  ounces),  there  was  found  disproportionate  thickness 
of  the  outer  or  barren  layer  (ependyma  formation  of  Mey- 

FiG,  12. 


nert)  of  the  cortex,  over  the  entire  expanse  of  the  two  cere- 
bral hemispheres.  With  this  there  was  a  relative  sparseness 
of  ganglionic  elements  in  the  other  parts  of  the  cortex,  par- 
ticularly'' noticeable  in  the  granular  layers.  The  two  accom- 
panying figures  illustrate  the  difference  between  the  normal 
cortex  and  that  of  the  imbecile;  it  is  a  suggestive  fact  that 
one  of  the  chief  respects  in  which  the  cortical  structure  of 
man  differs  from  that  of  the  lower  animals  is  in  the  relative 
reduction  of  the  barren  layer  at  the  expense  of  those  which 
are  rich  in  ganglionic  elements.  In  the  case  where  the 
relative  overgrowth  of  the  barren  layer  was  most  marked 
of  the  two  referred  to,  much  more  so  than  in  the  one  from 
which    the  illustration  was  taken,  the  walls  of  the  blood- 


286  INSANITY. 

vessels  were  found  to  be  sclerotic,  and  there  was  a  general 
preponderance  of  connective  tissue  elements  over  the  ner- 
vous structures  throughout. 

Another  condition  was  found  by  the  writer  which  at 
present  he  is  unable  to  offer  a  satisfactory  explanation  of. 
This  consists  in  the  presence,  in  large  numbers,  of  nuclear 
bodies,  surrounded  by  a  little  granular  protoplasm,  and 
contained  in  clear  round  spaces  of  the  neuroglia  (Fig.  if).!  I 
They  differ  from  the  similar  bodies  found  in  paretic  demen- 
tia and  in  other  organic  diseases  of  the  brain  in  the  fact 
that  they  incorporate  the  finely  granular  protoplasm  re- 
ferred to,  which  resembles  that  of  nerve  cells.  The  same 
kind  of  bodies  are  found  in  large  numbers  and  in  special 
layers  in  the  brains  of  the  lower  mammalia,  and  their  pres- 
ence in  the  cortex  of  the  imbecile  may  indicate  an  arrested 
state  of  histological  development. 

Among  the  anomalies  in  the  type  of  the  convolutions 
which  dave  been  studied  in  so  large  a  number  of  cases,  the 
most  interesting  are  the  deformities  of  the  occipital  lobe. 
The  latter  is  often  shortened,  or  the  seat  of  microgyria,  that 
is,  abnormal  smallness  of  the  gyri,  a  condition  which  is 
sometimes  associated  with  deficiency  of  the  splcnium  of 
the  corpus  callosum,  as  was  the  case  in  one  of  the  imbeciles 
who  were  examined  by  the  writer.*  In  several  Caucasian 
imbeciles  pathologists  have  found  the  gyrus  of  the  cuneus 
running  superficially,  as  in  the  chimpanzee,  and  the  so- 
called  "Affenspalte"  (ape-fissure)  of  the  convex  surface  of 
the  brain  (Fig.  12)  has  been  so  termed  because  it  imitates 
in  disposition  the  opercular  fissure  of  the  apes.  It  is,  how- 
ever, not  a  perfect  homologue  of  that  fissure,  though  its 
presence,  when  it  is  due  to  the  fusion  of  the  external  oc- 
cipital with  the  internal  perpendicular  occipital  sulcus,  is  a 
significant  sign  of  disturbed  cerebral  growth. 


CHAPTER  XXI. 

Monomania — Preliminary  Considerations. 

Probably  no  word  in  the  nomenclature  of  mental  science 
has  been  so  confusedly  used  and  has  led  to  so  much  mis- 
understanding, and  consequent  protest  against  it,  as  mono- 

*  "  The  Etiology  of  Insanity,"  loc.  cit. 


MONOMANIA — PRELIMINARY   CONSIDERATIONS.    287 

■mania.  By  this  term  the  great  Esquirol,  its  originator, 
designated  that  form  of  insanity  in  which,  while  the  mem- 
ory, the  conceptions,  and  judgments  generally  are  not  de- 
stroyed, and  no  pronounced  emotional  disturbance  exists, 
yet  the  patient  is  controlled  by  some  expansive  delusion  or 
•ambitious  project.  Esquirol's  failure  to  appreciate  the 
fundamental  feature  of  monomania  led  to  his  separation  of 
the  same  class  of  lunatics,  whose  delusions  are  of  a  for- 
mally sad  character,  under  the  term  lypemania  (melancholia), 
thus  placing  them  in  the  same  group  with  the  emotionally 
depressed  patients.  The  untenability  of  this  distinction 
must  be  evident  when  it  is  borne  in  mind  that  the  expan- 
sive delusion  of  him  who  to-day  believes  that  he  is  a  king, 
may  to-morrow  become  masked'  by  the  depressive  delusion, 
that  he  is  persecuted  by  the  usurper  of  his  throne;  or,  to  cite 
a  case  which  may  be  better  illustrated  in  American  asylums, 
the  projector  of  some  insane  invention,  who,  before  being 
•committed  to  an  institution,  revels  in  bright  anticipa- 
tions of  the  prospective  income  to  be  derived  from  it,  after 
his  interdiction  will  develop  the  depressive  delusion,  that 
the  invention  or  its  secret  has  been  stolen  from  him,  and 
that,  to  prevent  the  pressing  of  his  just  claims,  he  has  been 
immured  in  an  asylum  on  the  certificates  of  conspiring  phy- 
sicians. 

Esquirol's  pupils  and  contemporaries  recognized  that  so- 
called  "partial  insanity" — which  term,  when  divested  of  the 
erroneous  conceptions  still  clinging  to  it,  is  a  fair  vernacular 
rendering  of  "  monomania" — not  only  manifests  itself  in  dis- 
turbances of  the  conceptional  sphere,  but  sometimes  also  in 
morbid  impulses  and  affective  perversion.  Here  those  alien- 
ists who  delighted  in  burdening  the  infant  science  of  psy- 
chiatry with  new  systems  of  classification  found  a  fruitful 
field  for  innovation.  Whatever  the  direction  in  which  a 
lunatic  manifested  his  most  prominent  symptoms,  that  di- 
rection determined  the  coining  of  a  new  term  !  Persons 
who  exhibited  a  tendency  to  homicide  were  termed  homici- 
dal monomaniacs;  those  who  enjoyed  thieving  were  classed 
as  kleptomaniacs  ;  those  who  delighted  in  conflagrations 
were  denominated  pyromaniacs,*  and  so  on,  till  no  un- 
usual act  committed  by  the  insane  had  been  left  uncan- 
vassed.      The  designations  "  Gamomania,"  or  "  the  insane 

*  It  must  be  stated  here  that  some  of  these  terms,  having  become  as- 
sociated with  fixed  clinical  conceptions,  are  still  in  use,  and  have  ac- 
<juired  a  definite  meaning  and  position  in  science,  secondarily. 


288  INSANITY. 

desire  to  marry;"  and  "  Frauenschuhstehlmonomanie"  or 
the  "mania  for  stealing  women's  shoes,"  are  imperisha- 
ble monuments  of  this  folly.  From  the  dignity  of  a  clini- 
cal conception,  "  monomania"  sank  to  the  level  of  a  conven- 
ient label  for  trivial  and  often  incidental  symptoms;  and  it 
is  not  to  be  wondered  at  that  the  earlier  German  and  Eng- 
lish alienists,  finding  this  term  loaded  with  such  ballast  as 
that  alluded  to,  abandoned  it  altogether.  Thenceforth, 
until  the  later  revival  in  classification  took  place,  mono- 
mania was  crowded  into  the  mixed  group  of  the  secondary 
mental  states  under  the  non-committal  designation,  "chronic 
mania"  or  "chronic  delusional  insanity." 

The  French  writers,  uninfluenced  by  the  assaults  made 
by  Falret  and  Delasiauve,*  continued  to  use  the  term,  mak- 
ing the  proper  restrictions  and  differentiations  from  time  to 
time.  Baillarger  pointed  out  the  essential  distinction  be- 
tween the  melancholia  (lypemania)  and  monomania  of  Es- 
quirol,  while  Marce  showed  that  the  gay  and  expansive 
delusion  is  not  a  universal  characteristic  of  monomania,  inas- 
much as  many  patients  with  depressive  delusions  present 
the  same  perverse  logic,  and  particularly  the  same  antece- 
dents and  terminal  history  so  distinctive  of  monomania  as 
thus  far  recognized.  He  spoke  of  patients  of  that  class 
as  affected  with  sad  monomania,f  in  contradistinction  to  the 
older  recognized  form  which  he  classed  as  gay  monomania.^ 
With  slighter  modifications  this  sense  in  which  Marce  em- 
ployed the  term  became  generally  adopted,  and  monomania 
to  this  day,  as  a  name  for  a  form  of  insanity,  holds  its  place 
in  France— the  land  where  it  originated,  and  where  it  passed 
through  the  ordeal  of  a  now  historical  discussion  and 
criticism. 

While  to  Morel  belongs  the  credit  of  having  first  called 
attention  to  the  intrinsic  feature  of  the  monomaniac's  de- 
lusion, its  systematized  character,^  the  Germans,  who 
adopted  the  distinction  of  monomania  in  its  limited  and 
proper  sense  comparatively  late,  subsequently  did  much  to 

*  Whose  proposed  "  Pseudomonotnanie"  shows  that  he  recognized  the 
necessity  for  some  such  classification  as  that  attempted  in  the  group  of 
monomania. 

f  Mo7tomame  triste. 

XMotionianie  gaie;  it  is  noteworthy  that  the  eminent  American  clinician 
Rush,  probably  the  most  advanced  psychiatrical  thinker  of  his  day,  in 
some  degree  anticipated  this  distinction  in  his  Tristimania  and  Ametio- 
fnania. 

§  Hence  his  synonym,  "  Manie  systematisee." 


MONOMANIA — PRELIMINARY   CONSIDERATIONS.    289 

establish  it  on  a  firm  etiological,  pathological,  and  clinical 
foundation.  To  Snell*  and  several  of  his  contemporaries  we 
owe  a  clear  demarcation  of  the  systematized  insanities  as  a 
whole,  under  the  designation  pritndre  Verrucktheit."  The 
main  fact  which  they  determined  was,  that  these  systema- 
tized insanities  are  of  primary  origin,  and  not  secondary  to 
some  other  psychosis,  as  Griesinger  and  the  followers  of 
that  eminent  alienist  believed.  The  latter  taught  that  all 
the  pure  forms  of  chronic  insanities  are  secondary  trans- 
formations from  an  acute  primary  mental  disorder  of  the  na- 
ture of  a  simple  mania  or  melancholia.  This  is  indeed  true 
of  secondary  confusional  insanity  (Chapter  VIII.),  which  is 
sometimes  the  intermediate  stage  in  the  transformation  of 
acute  melancholias  and  manias  into  terminal  dementia; 
but  it  was  precisely  the  failure  of  the  older  German  alien- 
ists to  discriminate  between  this  secondary  form  and  true 
monomania  that  led  them  to  predicate  the  same  clinical 
development  characteristic  of  the  former  for  the  latter  as 
well,  on  a  priori  and  speculative  grounds.  Griesinger 
shortly  before  his  death  recognized  this  error,  and  formally 
accepted  the  doctrines  of  Snell.  To-day  the  German  alien- 
ists, by  a  resolution  of  their  association,  stand  unanimously 
committed  to  the  recognition  of  a  primary  form  of  chronic 
insanity  known  by  them  as  primdre  Verriicktheit,  and  equiv- 
alent to  the  7nonomanie  of  the  French. 

If  we  cast  a  glance  at  the  earlier  literature  with  reference 
to  the  category  of  patients  who  are  classed  as  monomani- 
acs, we  will  find  that  even  the  popular  mind  appreciated  in 
a  crude  way  the  distinctness  of  the  morbid  ideas  of  such 
subjects  from  the  ideas  of  those  suffering  from  other  forms 
of  insanity.  The  English  word  "cracked"  aptly  expresses 
that  there  is  but  a  flaw  and  a  relative  shifting  of  the  ele- 
ments of  the  understanding,  not  a  general  confusion  and 
annihilation  of  them.  Where  language  has  been  used  accu- 
rately such  patients  have  neither  been  termed  foolish  nor 
crazy.  From  distant  times  the  Germans  have  employed 
the  expressive  term  of  '■'fixe  Idee"  to  designate  the  delu- 
sions and  projects  which  are  so  prominent  features  of 
monomania,  and  which  are  popularly  rendered  by  theword- 
*  It  is  a  significant  support  of  the  views  announced  in  this  work  that, 
in  the  absence  of  any  other  good  English  equivalent  than  "  monomania" 
for  the  "  primare  Verriicktheit"  or  "  Wahnsinn"  of  the  Germans,  Snell 
himself  stated  that  Monomatiie  as  an  acceptable  German  synonym  for 
the  latter  term. 


290  INSANITY. 

pictures  "  a  bee  in  the  bonnet"  and  "  a  screw  loose."  The 
noun  '■'■Verriicktheit"  is  derived  from  the  vernacular  adjective 
verriickt*  which  is  a  good  metaphorical  equivalent  of  the 
English  "  cracked,"  and  perhaps  a  better  designation  in  so 
far  as  it  directs  attention  to  the  prominent  feature  of  mono- 
mania, the  mal-association  of  special  mental  components. 
The  authors  of  the  most  comprehensive  English  treatise 
on  insanity  f  exemplify  the  unsatisfactory  views  prevailing 
on  this  subject  in  the  following  lines:  "  We  heartily  wish 
'Monomania'  had  never  been  introduced  into  psychological 
nosologies;  for  if  understood  in  a  literal  sense  its  very  exist- 
ence is  disputed,  and  if  not,  the  various  morbid  mental  con- 
ditions it  is  made  to  include  by  different  writers  lead  to 
hopeless  confusion.  With  one  author  it  means  only  a  fixed 
morbid  idea;  with  another  only  partial  exaltation;  while  a 
third  restricts  it  to  a  single  morbid  impulse. 

If  words  were  to  be  eliminated  from  the  vocabulary 
merely  because  they  do  not  literally  correspond  to  their  ac- 
<iuired  and  accepted  meaning,  more  than  half  of  those  in 
the  medical  dictionary,  and  about  nine  tenths  of  those  em- 
ployed in  the  special  branch  of  mental  medicine,  would  have 
to  be  replaced  by  new  ones.  With  the  abuse  of  a  term  in- 
vestigators have  little  to  do;  and  while  the  distinguished 
authors  cited  are  fully  justified  in  their  criticism  of  the  one- 
sided and  narrow  interpretation  referred  to  by  them,  the 
reflection  cannot  be  suppressed  that  they  have  themselves 
not  accepted  that  view  of  monomania  which  has  so  much 
facilitated  classification  in  France  and  Germany,  and  which 
view  does  not  harmonize  with  their  later  statements:  that 
monomania  may  be  either  "delusional"  or  "emotional," 
and  may  under  certain  constructions  include  both  "  melan- 
cholia without  delusion,"  and  "exaltation  without  incohe- 
rence." That  monomania  is  a  just  conception  of  psychi- 
atry is  nowhere  better  shown  than  in  the  fact  that  the 
authors  of  this,  the  largest  recent  work  on  Psychological 
Medicine  in  the  English  language,  are  compelled  to  use  it  re- 
peatedly, and  find  no  better  designation  for  a  typical  case 
illustrated  in  the  frontispiece  of  their  volume  than  "  Mono- 
mania of  Pride."  Strictly,  monomania  may  be  construed 
to  mean  a  fragmentary  mania,  or  insanity  on  a  single  topic. 

*  Literally,  shifted  from  its  place. 

f  Bucknil'l  and  Tuke  :  "  A  Manual  of  Psychological  Medicine,"  4th  edi- 
tion, 1879,  p.  50.  In  the  present  treatise  all  these  objections  are  endorsed, 
but  only  as  applying  to  the  abuse  of  the  term. 


MONOMANIA — PRELIMINARY   CONSIDERATIONS.     29I 

Based  on  this  construction,  authors  have  stated  that  there  is 
no  such  mania,  and  that  there  is  no  insanity  on  a  single  topic, 
an  objection  that  must  be  sustained  at  least  for  the  majority 
of  cases.  But  in  medicine  we  cannot  afford  to  be  strict 
constructionists  of  terms  to  the  extent  of  quibbling  on  the 
etymological  signification  of  a  prefix.  On  the  same  grounds 
we  might  show  the  terms  insanity,  mania,  melancholia,  and 
hallucination  to  be  improper  and  inapplicable.  Yet  they 
are  sanctioned  by  usage,  and,  like  phthisis,  tabes,  hj^steria, 
etc.,  against  which  terms  similar  objections  may  be  urged, 
will  remain  in  our  nomenclature  to  the  end  of  time.  With 
the  limitation  that  the  prefix  shall  be  understood  to  denote 
that  the  insanity  extends  in  a  special  direction  across  the 
mental  horizon,  monomania  may  well  retain  its  place  in  our 
vocabulary.  The  term  chronic  partial  insanity,  which 
might  be  used  in  its  place,  is  objectionable  on  the  single 
ground  that  its  use  would  necessitate  the  incorporation  with 
monomania  of  other  forms.  The  term  "  delusional  insan- 
ity" is  objectionable,  for  the  reason  that  delusions  are  not 
essentially  features  of  all  varieties  of  monomania,  for  they 
may  be  entirely  absent  in  that  variety  which  is  character- 
ized by  imperative  conceptions,  and  they  are  found  promi- 
nently in  other  chronic  as  well  as  in  acute  forms  of  derange- 
ment. 

Sankey,  in  his  excellent  "  Lectures  on  Mental  Diseases," 
writes  :  "  The  popular  opinion  about  the  existence  of  mono- 
mania, I  need  scarcely  add,  is  a  very  erroneous  one.  The 
French  writers  use  the  term  "  monomanie"  in  a  much 
more  restricted  sense;  but,  to  avoid  confusion,  it  is  better  to 
avoid  the  term  altogether."  It  is  to  be  regretted  that  this 
author,  one  of  the  best  and  clearest  of  English  writers  on 
insanity,  had  not  investigated  more  closely  to  what  patients 
the  French  apply  the  term  monomania,  and  adopted  the 
sense  in  which  they  use  it,  under  some  equivalent  discrim- 
inating term.  If  he  had  done  so  he  would  not,  on  the  very 
same  page  containing  the  quoted  words,  have  confounded 
cases  of  the  most  widely  differing  forms  of  insanity.  In 
fact  his  group  of  the  "  Chronic  Insanities"  is  about  as 
practically  useful  and  as  clinically  sound  as  would  be  the 
uniting  in  ophthalmology  of  glaucoma,  microphthalmus,  re- 
tinitis pigmentosa,  and  cataract  in  one  group  of  "  Chronic 
Ophthalmia." 

A  third,  rather  popular  author,  Blandford,  is  responsible 
for  the  following  opinion,  which,  it  is  not  saying  too  much. 


292  INSANITY. 

could  never  have  been  written  if  he  had  fairly  represented 
the  views  of  the  continental  writers,  even  to  the  extent 
accomplished  b}'  the  previous  writer  referred  to.  "  Proba- 
bly what  is  most  commonly  called  monomania  is  chronic 
insanity,  where  the  patient  is  removed  from  deep  depression 
on  the  one  hand  and  gay  or  angry  excitement  on  the  other, 
and  when  the  bodily  health  has  assumed  its  ordinary  level, 
and  all  pathological  marks  have  by  time  been  effaced.  The 
distinction  between  mania  and  monomania  is  for  the  most 
part  verbal.  Formerly  all  insanity  was  called  melancholia, 
nowadays  it  is  spoken  of  as  mania,  and  if  chronic  as  mono- 
mania. There  is  nothing  pathological  in  such  a  nomencla- 
ture, and  it  only  serves  to  draw  us  away  from  the  due  con- 
sideration of  that  pathology  of  the  disease  we  have  to 
consider  and  treat.  We  may  retain  such  terms  as  acute  de- 
lirious mania,  acute  melancholia,  acute  dementia,  general 
paralysis,  because  they  denote  a  certain  set  of  pathological 
symptoms  occurring  in  individuals  of  various  ages,  requir- 
ing special  treatment  and  capable  of  receiving  a  similar 
prognosis.  We  may,  if  we  like,  retain  besides,  the  gen- 
eral terms  mania  and  melancholia,  but  beyond  this  we 
need  not  go;  any  further  distinction  should  be  made,  not 
according  to  mental  peculiarities,  but  according  to  the 
pathological  causes  or  conditions  of  the  case." 

It  is  not  true  that  "what  is  meant  by  monomania  is 
chronic  insanity,  where  the  patient  is  removed  from  deep 
depression  on  the  one  hand  and  gay  or  angry  excitement 
on  the  other."  Some  of  the  most  violent  scenes  in  the  asy- 
lum corridor  are  enacted  by  these  patients  under  the  influ- 
ence of  episodical  states  known  to  the  Germans  as  Primor- 
dialdelirien,  X.O  the  French  d^s  ^^  dc/ire  vesanique.''  Nothing 
could  beTnore  unfortunate  than  the  statement  that  mono- 
mania is  "  chronic  insanity  .  .  .  when  the  bodil}'^  health  has 
assumed  its  ordinary  level  and  all  pathological  marks  have 
by  time  been  effaced."  If  we  are  to  understand  Blandford 
as  meaning  by  "  pathological  marks"  all  the  indications  of 
the  pathological  mental  state,  then  we  must  conclude  that 
monomania  and  sanity  are  synonyms,  for  we  have  sanity 
when  all  the  pathological  marks  of  insanity  (the  most  char- 
acteristic and  essential  ones  being  the  mental  signs)  are 
effaced  !  But  if  we  are  to  understand  him  to  mean  by 
"  pathological  marks"  the  somatic  signs  of  insanity,  we  can 
only  conclude  that  he  has  involved  himself  in  a  profound 
contradiction  with    the   best    established    facts    of    mental 


MONOMANIA — rRELIMINARY   CONSIDERATIONS.    293 

pathology.  It  was  the  great  Morel  who  taught  that  mono- 
mania is  frequently  associated  with  somatic  signs  of  degen- 
eration. Now  such  somatic  signs  as  the  monomaniac  some- 
times shows  are  never,  under  any  circumstances,  effaced. 
This  fact  is  accepted  by  v.  Krafft,  Sander,  Meynert,  Westphal, 
Lombroso,Schuele,andgenerally  throughout  Germany,  Italy 
and  France.  In  view  of  the  fundamental  misappreciation  of 
certain  well-established  principles  of  modern  mental  medi- 
cine demonstrated  in  the  quoted  extract,  it  would  be  simply 
fruitless  and  superfluous  to  discuss  such  paradoxes  as  that 
the  "distinction  between  mania  and  monomania  is  for  the 
most  part  verbal,"  and  that  it  draws  us  away  from  "  the 
due  consideration  of  that  pathology  of  the  disease  we  have 
to  consider  and  treat."  The  facts  of  the  case  happen  to 
warrant  diametrically  opposite  conclusions. 

It  is  more  difficult  to  give  a  full  definition  of  monomania 
in  a  few  words  than  to  give  the  characteristics  of  any  other 
form  of  insanity  in  a  single  sentence.  It  is  altogether  too 
complicated  a  symptom  group  to  admit  of  a  brief  definition. 
It  is  a  constitutional  insanity,  almost  without  exception 
hereditary,  or  based  on  an  inherited  or  acquired  degenera- 
tive taint ;  it  involves  the  highest  logical  processes  primar- 
ily, but  does  not  warp  them  all  equally,  or  some  of  them,  in 
fact,  at  all.  On  first  sight  it  would  appear  to  merit  the 
designations  of  ideational  and  intellectual  insanity,*  pro- 
posed by  Maudsley  and  Hammond.  When  we  inquire 
more  deeply,  however,  we  find  that  here,  as  in  every  other 
group  of  mental  disorders,  attempts  to  classify  the  clinical 
forms  according  to  metaphysical  distinctions  are  predes- 
tined to  failure.  While  the  prominent  feature  of  these  in- 
sanities consists  in  a  series  of  ideational  aberrations,  im- 
perative conceptions,  delusive  interpretations,  systematized 
projects  and  actions,  or,  finally,  a  tendency  to  morbid  specu- 
lation, yet  we  find  that  they  are  not  always  free  from  an- 
omalies of  the  perceptional  sphere,  nor  free  from  disorders 
of  the  will. 

The  general  intellectual  status  of  these  patients,  though 
rarely  of  a  very  high  order,  is  moderately  fair,  and  often 
the  mental  powers  are  sufficient  to  keep  the  delusion  under 

*  The  term  intellectual  insanity,  in  the  absence  of  any  positive  justi- 
fication, has  not  the  advantage  of  age,  it  is  based  on  a  metaphysical  dis- 
tinction, it  does  not  cover  the  entire  ground  of  monomania,  and  it  covers 
a  great  deal  of  ground  outside  of  monomania.  Except  as  an  abstract 
symptom  designation  it  cannot  hold  a  place  in  clinical  psychiatry-. 


294  INSANITY. 

control  for  the  practical  purposes  of  every-day  life.  While 
many  are  what  is  termed  crotchety,  irritable,  and  depressed, 
yet  the  prominent  mental  symptoms  of  the  typical  cases  of 
this  disease  consist  of  the  fixed  delusions.  Since  the  sub- 
ject matter  of  the  delusion  is  of  such  a  character  that  these 
patients  consider  themselves  either  the  victims  of  a  plot,  or 
as  unjustly  deprived  of  certain  rights  and  positions,  and 
narrowly  observed  by  agents  of  their  foes,  delusions  of 
persecution  are  added  to  and  incorporated  in  the  fixed 
ideas,  and  they  become  sad,  thoughtful,  or  depressed  in 
consequence.  In  such  cases  the  erroneous  diagnosis  of 
"melancholia"  is  sometimes  made,  because  with  many,  de- 
pression, whatever  its  motive,  is  equivalent  to  melancholia. 
Now  such  a  case  is  no  more  melancholia  than  is  dyspepsia. 
The  patient  is  depressed  as  the  logical  result  of  reflections 
growing  out  of  his  morbid  train  of  ideas,  and  his  sadness 
and  thoughtfulness  have  causes  which  he  can  explain  and 
which  are  all  intimately  allied  with  that  peculiar  faulty 
grouping  of  ideas  which  constitute  the  rendezvous,  as  it  were, 
of  the  conceptions  of  the  patient.  Nay,  the  process  maybe 
reversed,  the  patient,  developing  a  hypochondriacal  state, 
imagines  himself  watched  with  no  favorable  eye.  Because 
he  is  watched  and  made  the  subject  of  audibie  comments 
(hallucinatory  or  illusional)  he  concludes  that  he  must  be 
a  person  of  some  importance.  Some  great  political  move- 
ment now  takes  place,  he  throws  himself  into  it,  either  in  a 
fixed  character  that  he  has  already  constructed  for  himself, 
or  with  the  vague  egotistical  idea  that  he  is  an  influential 
personage.  He  seeks  interviews,  holds  actual  conversations 
with  the  big  men  of  the  day,  accepts  the  common  courtesy 
shown  him  by  those  in  office  as  a  tribute  to  his  value,  is  re- 
jected, however,  and  then  judges  himself  to  be  the  victim  of 
jealousy  or  of  rival  cabals,  makes  intemperate  and  queru- 
lous complaints  to  higher  officials,  perhaps  makes  violent  at- 
tacks upon  them,  and,  being  incarcerated  in  a  jail  or  asylum, 
looks  upon  this  as  the  end  of  a  long  series  of  persecutions 
which  have  broken  the  power  of  a  skilled  diplomatist,  a  ca- 
pable military  commander,  a  prince  of  the  blood,  an  agent 
of  a  camarilla,  a  paramour  of  some  exalted  personage,  or, 
finally,  the  Messiah  himself.* 

All  through  this  train  of  ideas   there  is  seen  running  a 

*  It  may  be  well  to  state  that  these  lines  are  reproduced  without  alter- 
ation from  a  journal  article  published  a  year  prior  to  the  assassination  of 
President  Garfield. 


MONOMANIA — PRELIMINARY   CONSIDERATIONS.    295 

chain  of,  however  faulty,  reflections  and  inferences;  there  is 
no  absolute  gap  anywhere.  Indeed,  if  the  inferences  of  the 
patient  were  based  upon  correctly  observed  facts  and  prop- 
erly correlated  with  his  actual  surroundings,  his  conclu- 
sions would  sometimes  be  perfectly  correct.  With  regard 
to  matters  unconnected  with  their  morbid  ideas,  monoma- 
niacs present  the  ordinary  powers  of  memory  and  judg- 
ment, and  exceptionally  may  even  be  mentally  productive.* 
One  can  only  say  that  there  is  a  flaw,  a  break  in  the  logical 
apparatus,  and  a  weakening  of  the  logical  inhibitions;  not 
an  utter  confusion,  as  in  the  terminal  incoherence  of  other 
forms;  not  an  absolute  loss  of  power,  as  in  the  demented^ 
imbecile,  and  paretic;  not  a  fundamental  emotional  disorder, 
as  in  the  maniac  and  melancholiac. 

There  would  be,  strictly  speaking,  as  many  varieties  of 
monomania  as  there  are  patients  suffering  from  the  disease 
if  we  admitted  the  principle  of  classification  adopted  by  the 
earlier  French  writers;  for  every  monomaniac  develops  an 
aberration  of  judgment  or  conceptional  error  differing  from^ 
those  of  other  monomaniacs  in  some  respects.  Unless  such 
differences  are  due  to  differences  in  the  mechanism  of  the 
mental  malady  they  should  not  serve  as  grounds  of  sub- 
classification.  As,  however,  many  of  the  terms  which  have 
grown  out  of  the  unfortunate  tendency  previously  criticised 
cannot  be  violently  eradicated  from  our  nomenclature — par- 
ticularly, too,  because  they  are  in  part  acceptable  designa- 
tions for  the  special  direction  in  which  the  insanity  is  mani- 
fested in  well-defined  groups  of  monomania — it  may  be  well 
to  briefly  characterize  and  to  illustrate  one  of  them  as  a 
sample  at  this  point,  holding  to  the  reservation  previously 
expressed  as  to  the  value  of  such  groups. 

MEGALOMANiAf  is  a  term  applied  by  the  French  to  mono- 
mania manifesting  itself  in  delusions  of  a  socially  ambitious 

*  This  is  exemplified  in  the  case  of  that  Professor  Titel  referred  to  by 
Griesinger  ("  Mental  Pathology  and  Therapeutics"),  who,  laboring  under 
the  delusion  that  he  was  the  pope,  yet  continued  to  deliver  his  lectures  at 
the  University;  as  well  as  by  the  case  observed  by  the  writer,  of  a  patient 
whose  characteristically  insane  writings  are  cited  on  page  77,  and  who  made 
a  useful  invention  adopted  in  our  navy.  Another  instance  is  that  of  the 
religious  reformer,  Vanini,  burned  at  Avignon,  of  whom  an  interesting 
account  has  been  written  by  the  Marchioness  Clara  Lanza. 

t  Monomanie  vaniteuse  (French),  Grossenzaahnsinn  (German).  These 
terms  were  employed  before  the  great  distinctness  of  paretic  dementia 
was  recognized,  and  hence  have  been  erroneously  applied  to  the  unsys- 
tematized ambitious  delusions  of  that  disease. 


296  INSANITY. 

character.  The  patients  suffering  from  this  variety  of 
monomania  are  the  nobility,  princes,  political  reformers, 
inventors,  and  poets  of  the  asylum  ward.  In  one  marked 
example  of  this  kind,  which  the  writer  observed  at  the  New 
York  City  Insane  Asylum,  the  patient's  history  presented 
an  exaggerated  reflection  of  the  social  ambitions  which 
characterized  the  different  communities  in  which  he  lived; 
thus  strikingly  exemplifying  the  common  observation  that 
insane  delusions  are  caricatures  of  the  opinions  and  aspira- 
tions of  the  time  and  place  where  they  are  developed.  In 
an  absolute  monarchy  the  megalomaniac  believes  himself 
a  prince  or  duke,  in  a  semi-civilized  community  a  prophet 
or  a  Messiah,  and  in  a  republic  a  political  reformer.  In 
England  the  patient  referred  to  laid  claim  to  the  estates  of 
a  great  family,  on  the  ground  of  a  remote  and  doubtful  re- 
lationship to  an  earl;  in  France  he  threw  himself  into  the 
midst  of  the  revolution  of  1S4S,  and  was  actually  created  a 
general  by  Cavaignac;  in  New  York  he  competed  for  the 
office  of  comptroller,  one  of  the  fattest  in  the  land,  and  be- 
fore his  insanity  was  complicated  by  another  form  of  men- 
tal disease  he  devised  panaceas  for  quelling  the  troubles  in 
Ireland,  and  corresponded  extensively  with  Disraeli,  the 
British  ambassador,  and  Prince  Albert  on  this  and  other 
topics.* 

Patients  of  this  group  exhibit  a  characteristic  tendency 
to  associate  all  prominent  occurrences  and  personages  with 
themselves.  This  is  well  exemplified  in  the  following  record 
from  private  practice,  which  also  illustrates  the  main  feat- 
ures of  the  episodical  delirium  sometimes  interrupting  the 
ordinarily  calm  mental  state  of  such  patients: 

The  writer  was  called  to  examine  a  lady,  the  wife  of  a  pawn- 
broker, aged  about  forty-four,  and  visited  her  in  a  general 
practitioner's  capacity  at  the  request  of  a  relative  who  is  a 
physician;  she  received  him  without  reserve  and  exhibited 
considerablevolubilit}-;  the  great  difficulty  experienced  in  her 
examination  was  to  keep  her  to  the  line  of  inquiry  adopted, 
as  she  manifested  the  common  tendency  to  wander  off  to 
other  topics.  She  also  showed  marked  insanity  of  manner, 
and  by  the  time  the  writer  was  compelled  to  break  off  the  two 
hours'  interview  she  had  worked  herself  to  a  high  pitch  of  ex- 
citement and  become  vituperative  in  regard  to  her  husband, 
accusing  him  of  the  worst  crimes.     She  was  theatrical  in 

*  The  full  history  of  this  patient  is  detailed  on  page  iv-S" 


MONOMANIA — PRELIMINARY   CONSIDERATIONS.    297 

her  language,  in  her  attitude  and  gestures,  used  long  words, 
extracts  from  celebrated  works  of  fiction,  and  gave  a  highly- 
colored  account  of  her  intimate  relations  held  with  the 
minister  of  war,  high  military  officers,  and  the  higher  aris- 
tocracy while  in  Vienna,  her  native  city.  Her  own  state- 
ments revealed  that  these  intimate  relations  consisted  in  her 
leasing  her  husband's  villa  to  the  former,  in  bringing  one 
of  her  sons  to  a  military  school  under  the  control  of  the 
higher  military  officers  mentioned,  and  in  subscribing  with 
several  ladies  of  the  aristocracy  to  some  charitable  under- 
taking. From  her  husband's  account  it  was  evident  that 
the  patient  had  always  manifested  a  longing  to  enter  the 
higher  walks  of  society,  and  attached  great  importance  to 
the  most  trivial  transactions  between  members  of  the  aris- 
tocracy and  herself.  The  noticeable  outbreak  of  her  men- 
tal disorder  occurred  in  Vienna  seven  years  ago,  after  her 
husband  lost  something  like  a  million  florins  in  real  estate 
speculation.  At  that  time  an  electrotherapeutist  treated 
her  with  castoreum,  and  told  the  husband  that  the  disorder 
was  nervousness.  She  was  also  examined  by  Leidesdorf, 
but  his  opinion  had  not  been  satisfactorily  recollected  by 
the  husband.  At  that  time  she  had  nocturnal  hallucina- 
tions and  marked  delusions.  On  coming  to  this  country 
she  became  quieted,  though  numerous  documents  dating 
from  this  period  attest  that  she  still  entertained  ideas  that 
her  husband  had  wronged  her  financially  and  in  his  marital 
relations,  considering  her  high  social  and  financial  merits. 
A  year  ago  she  went  to  Hamburg  with  about  two  thousand 
dollars'  worth  of  jewelry,  which,  as  she  remarked  with  an 
affectation  of  cunning,  she  had  entrusted  to  the  purser  of 
the  vessel  without  a  receipt  or  other  voucher,  in  order  that 
her  relatives  might  not  get  hold  of  it.  In  Hamburg  she 
discovered  that  her  son-in-law  robbed  her  and  his  wife  of 
money  and  other  objects,  and  it  appears  that  she  was  con- 
fined for  six  weeks  in  the  insane  asylum  there.  She  had 
frequently,  within  the  last  year,  entered  her  husband's  place 
of  business,  and,  in  presence  of  customers,  accused  him  of 
the  foulest  crimes,  of  having  hired  a  prostitute  the  first 
night  of  their  marriage,  of  having  stolen  her  patrimony  to 
purchase  an  order  of  the  government,  and  finally  proceeded 
to  indict  her  whole  family,  with  the  exception  of  one  son 
and  a  nepliew,  as  being  engaged  in  a  conspiracy  against 
her.  The  son  in  question  presented  insanity  of  manner  far 
more  strikingly  developed,  even,  than  his  mother,  was  con- 


298  INSANITY. 

ceited,  arrogant,  and  excitable,  cut  his  father  short  when  he 
gave  me  the  hereditary  history  of  the  family,  and  behaved 
altogetlier  in  such  a  manner  that  the  writer  thought  it  best  to 
inform  him  that  it  would  require  the  greatest  care  on  his  part 
to  avoid  following  in  his  mother's  footsteps.  This  evidentl)^ 
produced  a  good  effect,  he  ceased  to  agitate  against  his 
mother's  examination  by  a  second  physician,  and  was  duly 
asserted  by  her  to  have  joined  the  conspirators.  The  nephew 
was  a  weak-minded  young  man.  and  the  evident  tool  of  his 
intellectually  vastly  superior  aunt.  She  had  instructed 
him  to  put  the  brakes  on  when  she  became  excited,  for  he 
took  away  a  document  which  she  was  about  to  present  to 
the  writer,  and  which  a  glance  showed  to  be  a  characteristic 
production,  being  full  of  underlining  marks,  exclamation 
points,  and  other  symbols.  From  receiving  the  writer  in  the 
capacity  of  a  physician  to  treat  her  "  nervousness,"  which  she 
evidently  did  merely  to  introduce  the  subject  of  her  alleged 
wrongs,  she  begged  him  to  take  charge  of  her  matters  in  the 
capacity  of  a  legal  adviser.  Her  memory  was  excellent,  her 
judgment  on  all  matters  not  connected  with  her  delusions 
sound,  and  even  brilliant,  in  this  respect  corresponding  to  the 
other  patient's  here  spoken  of.  Aside  from  her  son  and 
nephew,  on  both  of  whom  heredity  had  set  its  stamp,  she 
had  a  brother  dying  with  paralytic  insanity  at  an  Austrian 
asylum,  a  sister  affected  with  similar  symptoms  to  her  own 
in  another  institution,  and  an  uncle  also  deceased  in  an  as}'- 
lum.  After  the  visit  she  became  more  and  more  excited, 
kept  the  neighbors  awake  at  night  with  her  declamations, 
and  when  the  second  physician  arrived  to  examine  her  she 
spat  in  his  face. 

This  history  serves  to  illustrate  the  facts  to  which  atten- 
tion has  previously  been  called,  that  delusions  of  persecu- 
tion are  common  sequelae  of  delusions  of  aggrandizement, 
in  monomania,  and  that  the  two  may  exist  side  by  side.  A 
demarcation  between  monomanias  in  which  persecutory 
delusions  predominate  and  those  in  which  the  ambitious 
ideas  prevail,  it  is  impossible  to  defend  ;  they  are  merely 
the  same  disease,  manifesting  their  symptoms  under  differ- 
ent external  guises,  whose  formal  character  is  often  fos- 
tered if  not  determined  by  external  circumstances,  such  as, 
for  example,  an  arrest,  or  an  asylum  incarceration  following 
some  extravagant  act.  The  French  appear  to  have  been 
determined  in  their  classification  of  certain  delusional 
lunatics  as  megalomaniacs  by  the  vain  attitude  of  the  pa- 


MONOMANIA — PRELIMINARY    CONSIDERATIONS.    299 

tient.  This  ^^  attitude  orgueilleiise"  is,  indeed,  a  most  charac- 
teristic sign  of  the  malady  in  certain  cases  ;  everytliing, 
from  the  erect  and  stiffened  position  of  the  body,  the  up- 
turned head,  and  the  supercilious  sneer,  to  the  dramatic 
gestures,  and  the  air  of  condescension  displayed  in  conver- 
sation with  others,  typifies  the  dominant  egotism  of  the 
patient.  Occasionally,  however,  a  gross  delusion  of  the 
most  ambitious  kind  may  exist  without  displaying  itself  in 
the  external  appearance  or  conduct.  A  historical  instance 
is  that  of  an  inmate  of  a  Parisian  asylum,  whom  a  govern- 
ment commissioner,  after  a  prolonged  and  careful  examina- 
tion, was  about  to  discharge  as  a  person  of  indubitable  men- 
tal soundness,  and  who  displayed  nothing  abnormal  until, 
in  accordance  with  the  modus  of  discharge  in  use  there,  he 
was  requested  to  sign  his  name  to  the  discharge  papers, 
when  he  signed  liimself  "The  Christ." 

In  another  instance  whicli  came  under  the  writer's  own 
observation,  while  the  patient's  self-esteem  was  great  and 
his  ideas  were  expansive,  he  claiming  to  possess  a  large  and 
valuable  piece  of  land,  and  that  the  United  States  Govern- 
ment owed  him  several  miilions,  yet,  as  a  colleague  ex- 
pressed it,  his  manner  and  address  were  simply  such  as 
would  be  expected  of  a  courtly,  prosperous  man  of  busi- 
ness. In  great  contrast,  side  by  side  with  him  in  the  same 
ward,  was  a  patient  who,  notwithstanding  the  fact  that  he 
had  marked  delusions  of  persecution — such  as  that  Dickens 
had  written  "Bleak  House"  to  injure  him,  and  that  he  was 
annoyed  by  human  and  superhuman  agencies — manifested 
an  egotism  and  conceit  in  his  manner  and  in  his  writings 
which  could  not  well  be  excelled.  It  is  often  a  difficult  ques- 
tion whether  to  range  such  cases  under  the  head  of  megalo- 
mania or  persecutory  monomania  ;  and  it  is  best  to  designate 
them  as  "  monomania,"  adding  the  qualifyingclauses  "  with 
predominating  delusions  of  persecution,"  or  such  "  of  gran- 
deur," as  the  case  may  require. 

Not  only  the  expansive  and  depressive  tinge  of  delusive 
conceptions,  but  also  their  intrinsic  contents,  have  been  and 
are  still  made  the  basis  of  sub  classification.  Where  the  delu- 
sions grow  out  of  perverted  visceral  sensations,  or  relate  to 
the  condition  of  the  body,  we  have  the  so-called  hypochoH' 
driacal  insanity,  which  in  its  most  elaborate  development 
constitutes  the  nosomania  of  Guislain.  When  the  ideas  of 
the  patient  exhibit  a  hysterical  Im^c,  hyste?-ical  ittsanity  h.a.s 
been  asserted  to  exist.     The  predominance  of  religious  de- 


300  INSANITY. 

lusions  has  given  rise  to  the  term  religious  monomania  or 
theomaniaj  while  those  cases  where  the  morbid  ideation 
centers  around  some  real  or  imaginary  object  of  platonic 
love  pass  under  the  designation  erotomania.  Now  the  de- 
lusions of  the  erotomaniac  and  of  the  theomaniac  may  be  en- 
tirely expansive;  and  in  reality  erotomania  and  theomania 
are  in  their  inception  merely  varieties  of  megalomania  ; 
later  in  the  course  of  these  disorders  persecutory  ideas  are 
apt  to  arise,  and  may  predominate  to  such  a  degree  that 
the  patient  then  presents  the  picture  of  persecutory  mono- 
mania to  perfection.  Add  to  this  the  facts  that  the  religious 
delusion  is  merely  an  accidental  feature,  inasmuch  as  it  could 
not  exist  if  the  world  had  always  been  and  were  to-day  ag- 
nostic, and  that  the  same  patient  may  unite  in  his  delusive 
conceptions  the  features  of  hypochondriacal,  religious,  and 
erotic  monomania,  and  the  reflection  will  naturally  follow, 
that  however  well-established  the  great  group  of  monomania 
may  be,  nothing  is  gained  by  subdividing  it  into  varieties 
based  on  features  which  are  so  changeable,  and,  in  part,  so 
accidental  as  the  contents  and  tinge  of  the  delusions. 

For  the  rehabilitation  of  "  monomania"  in  its  wider  sense 
as  a  form  of  insanity,  including  at  least  a  quarter  of  the 
chronic  insane  population,  no  better  reason  can  be  assigned 
than  that  there  is  no  other  single  English  term  which  is 
sanctioned  by  usage  and  by  our  foremost  authors  on  the 
subject  which  covers  the  conception  of  an  insanit}^  charac- 
terized by  a  flaw  in  the  understanding  manifesting  itself 
in  a  special  direction.  Yet,  while  adopting  the  term,  and 
devoting  further  chapters  to  the  consideration  of  the  de- 
rangements falling  under  it,  grounds  have  been  advanced 
in  the  present  chapter  which  justify  the  ignoring  of  the 
more  minute  classification  of  the  monomanias  attempted  in 
the  first  half  of  this  century. 


MONOMANIA,    ITS   COURSE   AND   VARIETIES.        3OI 

CHAPTER  XXII. 

Monomania,  its  Course  and  Varieties. 

Monomania  is  a  chronic  form  of  insanity  based  on  an  acquired 
or  transmitted  neuro-degenerative  taint,  and  manifestifig  itself  in 
anomalies  of  the  conceptional  sphere,  which,  while  they  do  not  de- 
structively involve  the  entire  mental  mechanism,  dominate  it. 

While  monomania  is,  in  the  vast  majority  of  cases,  based 
on  an  inherited  taint  of  insanity  or  a  transmitted  neurotic 
vice,  it  may  also  develop  after  any  deep  or  sudden  injury 
to  the  nervous  system.  Thus  there  are  rare  cases  of  mono- 
mania which  have  developed  after  typhus  fever,  after  head 
injuries,  in  conjunction  with  alcoholism,  and  even  after 
functional  perversions  of  the  cerebral  faculties  occurring  in 
the  course  of  dreams.  There  can  be  very  little  doubt  that 
great  emotional  strain  and  the  continual  harping  of  the 
mind  on  one  subject  is  also  an  important  factor  in  the 
etiology  of  many  cases  of  monomania,  and  while  usually 
physical  disease  or  a  faint  neurotic  taint  may  be  found 
even  here,  there  are  exceptional  cases  where  the  most  care- 
ful examination  fails  to  determine  their  previous  existence. 

In  that  larger  number  of  cases  in  which  an  original 
neurotic  taint  is  found,  there  are  usually  noted  before  the 
actual  outbreak  of  the  disorder,  anomalies  of  character,  of 
the  general  nervous  functions,  and  of  the  somatic  constitu- 
tion. As  these  indicate  the  essential  basis  on  which  typical 
monomania  bursts  out  into  full  bloom,  warn  us  of  the 
danger  ahead,  and  sometimes  constitute  unfailing  criteria 
of  insanity  in  disputed  cases,  they  are  invaluable  to  the 
alienist.  The  somatic  signs  in  question  have  been  dis- 
cussed in  previous  chapters.  It  may  suffice  at  this  point 
to  refer  to  those  which  have  been  found  in  a  form  of  mono- 
mania which,  from  its  early  development  and  its  patent 
dependence  on  gross  structural  defect,  has  by  Sander  been 
termed  "  originare  Verriicktheit."  In  this  form  the  sub- 
jects are  noted  to  be  peculiar  from  infancy,  they  entertain 
vague  aspirations,  are  excessively  egotistical,  and  the  non- 
recognition  of  their  supposed  importance  or  abilities  leads 
them  to  consider  themselves  the  subject  of  persecution. 
In  others  the  egotism  is  so  great  that  the  most  ridiculous 
failures  are  not   capable  of  dispiriting  them,  but,  on  the 


302  INSANITY. 

contrary,  are  accepted  as  proofs  of  a  divine  mission  which 
is  to  be  carried  on  in  a  state  of  perpetual  martyrdom. 
Hallucinations  frequently  develop  as  the  disorder  pro- 
gresses. With  these  there  are  symptoms  of  neural  dis- 
order, similar  to  those  found  in  imbecility  and  idiocy:  some 
have  epileptiform,  others  choreiform,  and  still  others  quite 
peculiar  and  indefinable  movements  of  an  "imperative" 
kind.  Peculiarities  in  pronunciation  and  inability  to  pro- 
nounce certain  consonants  in  childhood  have  been  noticed 
in  others.  There  are  in  addition  defects  in  the  bodily  con- 
formation of  a  similar  kind,  though  usually  of  lesser  degree, 
than  those  characterizing  idiocy  and  imbecility;  the  head 
is  often  asymmetrical  or  deformed,  the  teeth  are  sometimes 
badly  developed,  and  there  may  be  club-foot,  strabismus, 
and  atrophy  of  one  side  of  the  body.  The  writer  has,  in 
several  cases,  found  anomalies  of  the  cerebral  architecture 
associated  with  those  of  the  skull  in  such  cases;  but  the 
most  instructive  case  on  record,  which  may  serve  at  once 
as  a  description  of  this  variety  of  monomania  and  as  an 
illustration  of  the  anatomical  conditions  found  with  it, 
may  be  here  cited  from  Muhr:* 

Ludwig  Schw exhibited  a  defect  in  the  development 

of  one  half  of  his  body  and  clumsiness  in  movements  from 
infancy.  He  did  not  learn  to  walk  until  ver}'  late,  and  then 
it  was  with  great  difficulty  that  he  could  be  induced  to 
assume  the  erect  posture.  He  preferabh'  walked  so  as  to 
support  himself  by  a  wall  or  other  objects  on  the  side  which 
was  defective.  His  figure  was  tall  and  slim,  and  a  stoop 
was  noticeable  throughout  life.  He  was  known  to  be  left- 
handed  from  childhood,  the  right  side  being  affected  with 
atrophy.  The  right  foot  was  shorter  and  sparer,  the  right 
hand  was  smaller  and  more  unserviceable  than  its  fellow. 
Strabismus  was  observed  from  the  period  of  adolescence; 
both  ocular  axes  converged  inward  and  downward,  more 
so  in  the  case  of  the  left  than  of  the  right  eye.  Vision  was 
defective  on  the  former  from  an  early  period,  and  he  was 
in  the  habit  of  twisting  his  head  round  so  as  to  utilize  the 
other  eye  in  reading;  ultimately  he  became  completely  am- 
blyopic on  both  sides.  He  had  no  sense  of  music  whatever. 
Notwithstanding  these  corporeal  defects  and  the  cerebral 
defect  to  be  detailed,  this  person  attained  a  considerable 

*Anatomische  Befunde  bei   einem  Falle  von  Verriicktheit,   von  Dr. 
Muhr. — Archiv  f.  Psych,  u.  Nervenkrankheiten,  vi.  p.  733. 


MONOMANIA,    ITS   COURSE  AND   VARIETIES.        303 

degree  of  education.  He  passed  college  and  the  university 
where  he  studied  law,  and,  aside  from  this  his  legitimate 
study,  he  devoted  attention  to  many  collateral  branches, 
receiving  the  best  testimonials  in  the  respective  depart- 
ments. Besides,  he  obtained  a  fair  knowledge  of  the  Italian, 
French,  English,  and  Sclavonic  languages.  He  was  a  per- 
fect master  of  Latin,  had  studied  the  whole  ecclesiastical 
literature  in  that  language,  gave  instruction  himself  in  the 
different  languages  mentioned,  and  was  constantly  engaged 
in  some  one  or  other  literary  production.  He  shifted  round 
a  great  deal  among  the  different  vocations  that  were  open 
to  him;  he  was  at  one  time  studying  with  a  notary,  at 
another  engaged  in  the  Department  of  Finances,  at  still 
another,  in  the  Trade  Chamber.  All  this  time  he  mani- 
fested a  morbid  desire  to  enter  a  cloister,  and  at  his  thirty- 
sixth  year  he  succeeded  in  being  admitted  to  the  novitiate 
in  a  Benedictine  institution,  where  he  stayed,  however,  only 
one  year.  It  was  his  habit  to  endeavor  to  attain  any  desired 
position  by  the  circuitous  channel  of  patronage,  and  from 
his  boyhood  up  he  had  exhibited  an  anxious  desire  to  at- 
tract to  himself  the  attention  of  influential  patrons.  His 
moral  sense  was  entirely  perverted.  He  bored  the  digni- 
taries of  the  church  with  reformatory  projects,  was  in  con- 
sequence recognized  as  a  lunatic,  and  sent  to  the  asylum. 
Previous  to  this  period  his  insanity  had  been  so  little  sus- 
pected that  at  one  time  he  had  actually  been  appointed 
curator  for  the   property  of   his    insane    sister,   Marianna 

Schw ,   by  court,   a  position   he   held    till    the    latter's 

death,  that  is,  from  i860  to  1861.  He  had  a  decided  antip- 
athy to  the  normal  gratification  of  the  sexual  desire,  and 
was  a  persistent  onanist  to  his  dying  day.  He  had  remark- 
able views  concerning  marriage,'  and  wrote  a  treatise  in 
defence  of  polygamy,  sustaining  his  position  by  means  of 
voluminous  quotations  from  ecclesiastical  authors.  Hallu- 
cinations could  be  demonstrated  to  have  existed,  dating 
from  his  twenty-fifth  year.  At -that  time  he  received  the 
revelation  that  he  was  the  Saviour  of  the  world  by  means 
of  hallucinations;  he  concealed  this  revelation  for  fifteen 
years,  absolutely.  Just  previous  to  this  he  had  delusions 
of  persecution  with  a  strong  sexual  tinge  and  of  a  repulsive 
and  disgusting  character.  He  then  began  to  consider  all 
remarks,  even  of  the  most  indifferent  character,  made  by 
strangers  as  applying  to  himself,  and  interpreted  them  as 
of  great  importance.     He  claimed  that  the  pope,  in  declar- 


304  INSANITY. 

ing  (1864)  "that  the  Star  which  was  destined  to  relieve  the 
Church  of  its  persecutors  was  about  to  appear,"  referred  to 
him.  In  consequence  of  his  delusive  interpretations  of  re- 
marks made  by  strangers  he  became  involved  in  conflicts 
in  restaurants,  having  gone  the  length  of  pronouncing  the 
strangers  intoxicated.  In  short,  delusions  of  an  expansive 
character  were  continually  alternating  with  those  of  a  de- 
pressive kind.  Between  this  time  and  the  asylum  sojourn 
he  had  at  different  periods  hallucinations  of  a  ceremonial 
nature,  such  as  that,  in  1863,  the  Archangel  Michael  appeared 
with  a  flaming  sword  amid  the  sound  of  trumpets,  to  notify 
him  that  he  should  prepare  himself  for  extraordinary 
events.  In  1864,  after  a  prolonged  period  of  fasting  and 
praying,  he  saw  God  himself  in  a  vision,  telling  him  that 
he  was  called  to  occupy  the  pontifical  chair;  at  the  same 
time,  he  added,  the  vision  informed  the  faithful  in  the 
church  at  the  time  that  "  this  is  my  beloved  Son,  him  shall 
ye  hear."  The  following  year  he  saw  the  Virgin  Mary, 
and,  observing  that  he  was  becoming  bald,  the  next  day  de- 
clared this  to  be  the  tonsure  which  she  had  conferred  on 
him.  Previous  to  his  admission  to  the  asylum  he  had  an 
occasional  perception  of  the  fact  that  his  actions  were 
erratic,  and  that  he  was  considered  a  fool,  a  fanatic,  and 
even  a  lunatic  by  the  priests  whom  he  was  in  the  habit  of 
persecuting  with  his  attentions.  In  1870,  having  been  per- 
suaded by  the  clergy  whom  he  communicated  his  projects 
to,  to  consult  an  alienist,  he  was  pensioned  off  by  the  gov- 
ernment, under  which  he  held  a  position  at  the  time,  and 
received  at  the  asylum  of  Feldhof.  Here  he  became  gradu- 
ally more  perverse  in  his  logic,  and  ceased  to  correct  his 
delusions.  While  at  the  asylum  he  entered  into  unnatural 
sexual  relations  with  a  weak-minded  epileptic,  and  the  two 
were  finally  discovered  together  in  a  water-closet,  and 
transferred  to  separate  parts  of  the  institution.  Whenever 
he  had  his  periods  of  religious  exaltation  he  indulged  in 
onanism,  and  he  was  on  one  occasion  found  reading  the 
legend  of  a  female  saint  and  masturbating  at  the  time.  He 
also  had  hallucinations  of  sexual  congress  with  the  female 
saints,  accompanied  by  seminal  emissions.  He  reached  the 
age  of  47  years. 

There  was  a  bad  hereditary  history  in  this  case  on  both 
sides.  On  the  paternal  side  nothing  is  known  definitely  as 
to  the  great-grand  and  grandparents  of  the  patient.  The 
latter  had  six  children,  of  whom  Charles  (the  father  of  the 


MONOMANIA,    ITS   COURSE   AND   VARIETIES.        305 

patient)  was  abnormal  from  infancy  and  notorious  for  his 
eccentricity.  He  died  suddenly  of  cerebral  haemorrhage. 
The  next  three  children  do  not  present  a  clear  history; 
there  were  grave  indications  of  heredity,  however.  The 
last  two  (females)  founded  families  said  to  be  mentally 
healthy.  On  the  maternal  side  an  uncle  was  a  priest,  with 
a  notable  absence  of  all  musical  sense,  and  dying  suddenly 
with  cerebral  haemorrhage.  His  sister,  the  mother  of  the 
patient,  is  said  to  have  been  of  a  normal  mind.    Aside  from 

the  patient,  Ludwig  Schw ,  there  were  six  children  in 

the  famil}'-;  the  first,  of  a  romantic  disposition,  went  to 
America  and  was  never  heard  of  again.  The  second  was 
the  aforesaid  Ludwig.  The  third,  a  girl,  had  a  beard  on 
her  chin,  exhibited  expansive  delusions,  and  died  in  the 
asylum.  The  fourth  was  born  blind  and  died  as  a  child. 
The  fifth  died  insane.  The  sixth  is  living;  he  is  an  en- 
gineer, right-handed,  cannot  use  his  right  leg  as  well  as  his 
left,  is  without  any  mental  defect,  and  has  several  sons,  not 
yet  grown  up  to  manhood,  and,  so  far  as  ascertained,  well 
developed,  with  the  exception  of  Emmerich,  aged  14.  The 
latter,  a  bright  boy,  is  left-handed,  the  right  extremity  being 
generally  less  voluminous  than  the  left,  and  the  right  hand 
measuring  half  an  inch  (1.5  cm.)  less  in  the  metacarpo- 
phalangeal line  than  its  fellow.  He  does  not  use  this  hand. 
The  right  half  of  his  cranium  is  noticeably  smaller  than 
the  left,  particularly  as  regards  the  parietal  boss.* 

The  examination  of  the  brain  showed  it  to  be  far  be- 
low the  average  of  the  adult  male  brain  in  size  and  weight; 
the  most  remarkable  feature  was  the  notable  and  unusual 
asymmetry  of  its  two  halves.  Dr.  Muhr  attributes  this 
asymmetry  to  the  reduction  in  volume  of  the  left  half  of 
the  cranial  cavitj''  and  of  the  left  internal  carotid  artery. 

The  general  impression  created  by  looking  at  the  skull 
was,  that  the  actually  longer  right  half  had  clasped  round 
the  shorter  left  half  so  as  to  accommodate  the  general 
shape  of  the  skull  to  an  ellipsoid.  It  was  also  observed 
that  the  region  of  the  sagittal  suture  was  carinated,  the 
suture  itself  being  but  little  serrated.  The  temporal  ridges 
rose  unusually  high  so  as  to  come  within  48  mm.  on  the 
right  and  36  mm.  on  the  left  side  of  the  sagittal  suture.  The 
frontal  region  was  retreating,  and  the  supraorbital  margins 

*A  most  remarkable  deviation  from  the  rule  that  the  bodily  and  cere- 
bral defects  are  on  opposite  sides. 


306  INSANITY. 

were  very  prominent.  The  left  half  of  the  cranial  cavity  was 
reduced  in  every  dimension,  the  ideal  horizontal  axis  of  the 
skull  would  have  to  have  been  represented  by  a  curved  line. 
As  if  to  compensate  for  the  defect  on  the  left  side  of  the 
cranium  the  face  deviated  to  the  other  side,  so  that  the  ver- 
tical ideal  plane  of  the  skull  was  slightly  S-shaped.  The 
left  cerebellar  fossa  was  scarcely  one  third  as  capacious  as 
the  right.  The  right  transverse  sinus  was  shallow  and  the 
right  jugular  foramen  narrowed,  while  the  left  sinus  was  well 
formed  and  its  foramen  of  fair  dimensions.  The  openings 
of  the  carotid  canal  as  well  as  the  canal  itself  were  abnor- 
mally small  on  the  left  side,  the  left  optic  foramen  being 
also  smaller  than  its  fellow.  The  clivus  was  very  steep 
owing  to  the  foreshortening  of  the  entire  skull.  The  cli- 
noid  processes  were  unsymmetrical,  the  right  ones  being 
the  larger. 

This  unusual  degree  of  cranial  asymmetry  was  the  direct 
cause  of  the  atrophic  state  of  the  left  side  of  the  enceph- 
alon,  and  in  its  turn  due  to  the  asymmetry  of  the  great 
vessels  supplying  the  skull  and  brain  with  blood,  according 
to  the  interpretation  of  the  matter  made  by  Muhr. 

On  passing  to  a  study  of  the  brain  itself,  it  was  found 
that  its  deformity  was  partly  due  to  a  relative  atrophy  of 
all  the  parts  of  the  encephalon  lying  to  the  left  of  the  median 
line,  partly  to  an  actual  absence  of  certain  parts. 

The  two  halves  of  the  cerebellum,  for  example,  were  so 
unlike  each  other  that  one  half  might  have  been  supposed  to 
have  been  derived  from  a  different  brain  than  the  one  from 
which  the  other  half  was  obtained,  if  they  had  been  seen 
separately.  The  difference  was  most  marked  on  the  inferior 
aspect;  the  left  cerebellar  hemisphere  was  a  round  lump, 
with  gyri  not  running  parallel,  as  in  the  normal  cerebellum, 
but  diverging  in  every  direction,  and  the  lobules  appeared 
twisted  on  themselves.  The  flocculus  was  rudimentary,  the 
amygdala  altogether  absent  on  the  left  side.  On  that  side 
the  gyri  (folia)  of  the  inferior  and  posterior  face  numbered 
eighty,  on  the  right  or  better  developed  side  only  sixty. 
This  discrepancy  was  due  to  the  fact  that  in  the  former 
enumeration  are  included  not  only  those  folia  which  reach 
and  are  counted  in  the  surface  of  the  normal  cerebellum, 
but  also  the  collateral  branches  which  here  extended  to  the 
surface,  owing  to  the  atrophic  condition  of  the  terminal 
lamellae. 

The  left  cerebral  hemisphere  was  in  every  respect  unlike 


MONOMANIA,    ITS   COURSE   AND   VARIETIES.        307 

its  fellow.  Shorter  and  less  massive,  it  were  particularly  its 
parietal  occipital,  and  temporal  lobes,  which  appeared  much 
reduced,  and  this  reduction  extended  to  the  half  of  the  cor- 
pora quadrigemina  and  the  basal  ganglia  of  that  side.  The 
left  optic  tract  and  right  optic  nerve  were  smaller  than  the 
right  tract  and  left  nerve;  the  left  corpus  mammillare  ap- 
peared to  be  absent,  the  right  well  developed.  The  right 
olivary  eminence  was  smaller  and  the  left  auditory  nerve 
narrower  than  their  fellows. 

The  fissure  of  Rolando  was  situated  further  backward 
on  the  left  hemisphere  than  on  the  right.  The  left  parallel 
fissure  opened  into  the  transverse  occipital;  there  was  a 
small  concealed  gyrus  to  indicate  their  separation.  The 
right  parallel  fissure  ran  into  the  post-central.  On  the  left 
side  the  calcarine  and  parieto-occipital  fissures  failed  to 
meet.  Altogether  there  was  observable  a  difference  in  type 
of  the  fissures  of  the  two  sides,  these  being  more  of  the 
longitudinal  pattern  on  the  left — more  of  the  transverse 
pattern  on  the  right  side.  The  length  of  the  corpus  callo- 
sum  was  64  mm.;  that  of  the  right  cerebral  hemisphere,  140 
mm.;  of  the  left,  120  mm.;  the  width  of  the  former,  60  mm.; 
of  the  latter,  50  mm.:  of  the  right  cerebellar  hemisphere 
50  mm.;  of  the  left,  33  mm.  The  right  olfactory  tract  was 
narrower  than  the  left. 

In  another  case,  equally  carefully  studied  by  Kirchhoff,* 
where  the  mother  and  grandmother  as  well  as  an  uncle  and 
aunt  on  the  maternal  side  had  been  insane,  the  patient  had 
had  epileptic  attacks  up  to  her  seventh  3fear.  She  appeared 
to  be  mentally  and  physically  healthy  from  that  time  up  to 
her  twenty-fourth  year,  when  an  emotional  disturbance  pro-  n 
voked  monomania  of  a  persecutory  charactery.  The  sole  of  }/^ 
the  right  foot  was  found  narrower  and  longer  than  that  of 
the  left,  the  right  kidney  showed  the  embryonic  lobulation, 
while  the  left  was  normal,  the  skull  was  microcephalic,  and 
the  left  hemisphere  did  not  cover  the  cerebellum  ;  in  addi- 
tion the  cerebral  commissures  were  defective,  and  there 
was  a  porencephalic  defect  in  the  left  gyrus  lingualis. 

The  bearing  of  the  somatic  anomalies  found  in  Muhr's, 
Kirchhoff's,  Sander's,  and  the   writer's    cases  *    of    original 

*  Arckiv  flier  Psychiatric,  xiii.  p.  168. 

*  The  Somatic  Etiology  of  Insanity:  being  the  W.  &.  S.  Tuke  Prize 
Essay  of  the  British  Medico-Psychological  Association,  published  as  the 
supplement  of  the  American  Journal  of  Neurology  and  Psychiatry, 
1882-83. 


308  INSANITY. 

monomania  must  be  analyzed  from  an  embr5'ological  point 
of  view  (page  86). 

Even  in  cases  where  the  somatic  signs  are  not  as  patent 
as  in  the  group  to  which  Sander  has  applied  the  designa- 
tion of  congenital  i?ionofnania  (originare  Verriicktheit),  anom- 
alies of  the  character  are  frequently  noted  in  early  life. 
Thus  one  lady  now  under  the  writer's  treatment,  suffering 
from  that  abortive  form  known  by  the  French  as  folie 
du  doiite  avec  de'lu-e  dii  toucher,  had  been  remarkable  as  a  girl 
for  her  timidity  before. visitors,  hiding  away  in  closets  at 
some  times,  and  at  others  insisting  on  having  a  certain 
dress  before  appearing  among  her  own  cousins.  Others, 
particularly  females,  exhibit  hysterical  peculiarities  and 
emotional  disturbances.  Many  of  these  patients  are  mor- 
ally imbecile  ;  they  are  devoid  of  an  inherent  moral 
sense,  and  this  defect  is  usually  found  to  be  associated 
with,  if  not  dependant  on,  a  morbid  egotism  which  recog- 
nizes no  rights  on  the  part  of  others,  including  the  pa- 
tient's relatives,  that  the  patient  feels  bound  to  respect, 
except  from  motives  of  expediency. 

The  general  nervous  and  mental  state  of  patients  pre- 
disposed to  monomania  has  been  aptly  characterized  by 
the  Germans  as  "  reizbare  Schwitche  " — irritable  weakness. 
It  manifests  itself  in  early  life  by  a  tendency  to  convulsions 
and  to  delirium  in  the  course  of  slight  febrile  affections. 

While  attention  has  been  called,  by  more  than  one  of  the 
classical  writers  on  insanity,  to  the  fact  that  the  intellectual 
faculties  in  this  condition  may  be  in  part  intact,  that  the 
memory  may  be  excellent,  and  the  judgment  on  ordinary 
matters  unimpaired,  yet  there  is  seldom  any  higher  ability. 
These  subjects  may  succeed  in  a  routine  calling,  but  they 
are  rarely  capable  of  a  sustained  mental  effort  in  an  original 
direction;  the  remarkable  exceptions  recorded  prove  the 
rule.  Usually  their  conceits  are  bizarre  rather  than  pro- 
ductive, their  reasoning  paradoxical  rather  than  logical, 
and  their  argumentation  tricky  and  shrewd  rather  than 
substantial.  To  the  laity  such  subjects  often  appear  to  be 
brighter  than  the  common  run  of  mankind,  because  com- 
monly oddity  is  mistaken  for  brilliancy,  and  unblushing 
pretence  for  merit.  When  the  whole  career  of  such  sub- 
jects is  followed  up  it  is  found  to  be  exceedingly  checkered, 
and  vagabondage,  theft,  and  fraud  are  often  prominent 
incidents  of  their  lives.  Sexual  perversion  has  been  noted, 
and  it  may  or  may  not  be  related   to  this  subject  that  fe- 


MONOMANIA,   ITS   COURSE   AND   VARIETIES.        309 
/ 

male  patients  belonging  to  this  group  sometimes  have  a 
beard  on  the  chin. 

In  a  limited  number  of  patients  the  continued  existence 
of  the  monomanical  character  is  the  chief  or  sole  manifes- 
tation of  mental  abnormality.  Pinel  the  nephew  described 
such  subjects  as  "  turbulent,  indocile,  quick  to  anger,  com- 
mitting outrageous  acts;  which  they  are  always  ready  to 
justify  by  plausible  reasons,  and  who  are  to  their  families, 
their  kindred,  and  their  friends  continued  subjects  of 
anxiety  and  grief.  They  are  continually  doing  wrong, 
either  by  neglect,  by  malice,  or  by  wickedness.  Incapable 
of  mental  or  physical  application,  they  destroy,  subvert, 
and  unsettle  everything  with  which  they  are  brought  into 
contact  and  which  they  can  injure."  Hallucinations  and 
fixed  delusions  may  be  entirely  absent,  but  the  overbearing 
egotism  of  these  patients,  wiiich  leads  them  to  the  most 
fanciful  and  extravagant  undertakings,  can  be  regarded 
only  as  the  expression  of  delusive  opinion.  From  the  fact 
that  they  are  capable  of  reasoning  readily  and  with  a  show 
of  ability,  and  manufacture  plausible  excuses  for  their  be- 
havior and  acts,  they  have  been  termed  reasoning  monomani- 
acs. This  designation  is  hardly  accurate;  the  patients  rea- 
•  son  with  facility,  it  is  true,  but  they  are  as  unreasonable  in 
their  beliefs,  and  more  so  in  their  acts  sometimes,  than  the 
delusional  monomaniac.  The  writer  suggests  terming  this 
disorder  monomania  sine  delirio,  for  it  bears  the  same  relation 
to  monomania  with  delusion  that  melancholia  sine  delirio 
bears  to  melancholia  with  delusions,  or  which  hypomania 
bears  to  typical  mania. 

An  interesting  case  of  this  kind  recently  came  under  the 
writer's  observation.  The  son  of  the  member  of  a  manu- 
facturing firm  in  one  of  our  larger  cities,  laboring  under 
certain  suspicions  regarding  a  business  associate  of  his 
father's,  took  a  bomb  into  the  place  of  business,  intending 
to  "  clean  out"  the  firm,  and  particularly  to  kill  the  obnox- 
ious member  of  the  latter.  He  exploded  the  bomb,  de- 
molishing the  entire  store  front,  killing  his  uncle,  wound- 
ing the  object  of  his  wrath,  and  injuring  himself  mortally. 
He  then  drew  a  revolver,  and  discharging  it  against  him- 
self, made  sure  of  his  own  death.  It  was  a  cousin  of  this 
unfortunate  person  who  came  under  the  writer's  care.  He 
had  acted  oddly  for  some  time,  not  committing  a  single 
act,  however,  which  he  could  not  explain  away,  or  render 
justifiable  in  the  eyes   of  the  laity.     The  writer  examined 


3IO  INSANITY. 

him  after  an  escape  from  an  asylum  in  which  he  had  beer^ 
placed,  and  from  which  he  had  managed  to  free  himself 
with  considerable  cunning  and  deliberation.  Beyond  a  bad 
conformation  of  the  skull,  an  abnormal  dentition,  spas- 
modic action  of  the  facial  muscles,  the  insane  manner^  and  a 
delusive  opinion  which  accurately  imitated  that  of  the 
bomb-throwing  relative,  the  patient  manifested  no  sign  of 
insanity  whatever.  In  view  of  the  threats  he  had  made, 
and  the  projects  he  had  expressed,  but  which  he  dissimu- 
lated at  the  time  of  the  examination,  the  writer,  with  a 
well-known  fellow-physician  of  New  York,  decided  to  place 
him  in  an  asylum.  About  this  time  there  was  a  "  liberation 
epidemic"  of  alleged  sane  persons.  A  lawyer  became  "  in- 
terested "  in  the  case,  and  a  general  practitioner,  as  well  as 
an  alienist  of  repute,  were  requested  to  examine  the  patient 
by  the  "  liberators."  Both  reported  him  sane,  grounding 
their  belief  not  only  on  the  calm  and  rational  behavior  of 
the  patient,  but  in  great  part  on  the  statement  of  an  as- 
sistant asylum  physician,  to  the  effect  that  he  had  observed 
nothing  "  wrong"  about  him.  The  patient  was  accordingly 
discharged  and  sent  "abroad;"  that  refuge  for  those  of 
the  insane  whom  their  liberators  wisely  hesitate  to  assume 
the  risk  of  attempting  to  manage.  Exactly  six  weeks  later 
the  same  patient  was  sent  to  the  same  asylum  (on  the  cer- 
tificates of  the  two  physicians  who  had  reported  him  sane) 
in  a  greatly  excited  condition  and  with  symptoms  of  early 
deterioration.  The  commitment  to  the  asylum  had  un- 
doubtedly anticipated  a  repetition  of  the  tragedy  which 
was  enacted  by  the  cousin  afflicted  with  the  same  form  of 
insanity,  suffering  from  the  same  delusive  belief,  and  har- 
boring the  same  morbid  project  five  years  before.  The 
opinion  given  that  the  patient  was  insane,  vindicated  as  it 
was  by  the  subsequent  history  of  the  case,  rested  on  what 
to  the  laity  and  to  some  of  our  colleagues  would  have  ap- 
peared trivial  if  not  fanciful  grounds;  and  the  case  is  de- 
tailed chiefiy  because  it  illustrates  the  importance  of  the 
somatic  signs  in  determining  the  existence  of  the  subtle 
form  of  insanity  which  is  the  subject  of  this  chapter,  and 
which,  in  some  of  its  phases  at  least,  may  be  aptly  desig- 
nated a  hypertrophy  of  character  in  an  abnormal  direction. 
In  many  cases  of  monojnania  sine  delii'io  a  periodical  out- 
burst of  excitement,  coupled  with  impulsive  acts  or  marked 
by  hallucinations,  is  noted.  These  constitute  a  transition 
to  impulsive  and  delusional  monomania,  and  the  periodical 


MONOMANIA,   ITS   COURSE   AND   VARIETIES.        31I 

recurrence  of  the  insane  explosions  is  an  illustration  of  the 
relationship  existing  between  all  the  forms  of  insanity 
which  are  the  expression  of  a  continuous  neurotic  vice,  of 
several  of  which  the  periodical  recurrence  is  character- 
istic. 

The  symptoms  of  classical  monomania  maybe  numerous 
and  varied,  or  they  may  be  few  and  limited  in  range.  In 
some  patients,  usually  encountered  without  asylums,  a 
single  imperative  conception  or  impulse,  or  a  delusive 
suspicion  which  may  never  become  organized  into  an 
insane  belief,  may  be  the  sole  mental  symptom.  Some  of 
these  cases  may  be  looked  upon  as  abortive  cases  of  mono- 
mania, an^  as  within  the  border  land  separating  sanity 
from  insanity,  while  others  are  undoubtedly  insane  in  every 
sense  of  the  word.  Vague  fears  are  experienced  by  some 
patients;  they  dare  not,  as  in  one  of  the  writer's  cases,  go 
to  a  certain  part  of  New  York  city  without  experiencing  a 
nameless  terror;  others  imagine  that  they  can  do  harm  by 
glancing  at  objects  in  a  certain  way.  One  patient  present- 
ing the  latter  symptom,  who  could  never  glance  at  a  crucifix: 
without  imagining  that  some  "flash-like  action"  was  ex- 
cited by  her  on  it,  could  not  be  convinced  by  the  clergy,, 
notwithstanding  her  devoutness,  that  it  was  an  absurd  be- 
lief on  her  part.  The  folic  du  doute  avec  delire  du  toucher  of 
Le  Grand  du  Saulle,  is  a  variety  of  abortive  monomania.* 
In  a  patient  presenting  this  symptom,  who  came  under  the 
writer's  care  since  the  present  volume  has  gone  to  press,  the 
fear  of  defilement  ordinarily  found  in  this  disorder  was 
replaced  by  a  fear  of  doing  herself  an  injury.  Her  sister- 
in-law  was  compelled  to  sift  her  food  to  see  that  no  glass 
had  gotten  into  it;  she  would  not  eat  with  a  fork,  and 
finally  dreaded  a  spoon.  She  did  not  dare  to  go  out  on  the 
street  without  a  veil  on  her  face,  because,  frail  as  the  fab- 
ric of  the  veil  was,  it  gave  her  a  certain  sense  of  security 
against  the  countless  dangers  she  feared.  On  one  occasion 
the  writer  ordered  her  to  take  the  veil  off,  to  give  it  to  him, 
and  to  go  home  on  foot;  the  relatives  were  ordered  to  use 
stern  measures;  the  examination  of  her  food,  which  had 
been  done  to  humor  her,  was  forbidden,  separate  cooking 

*  The  "  Griibelsucht"  of  Griesinger  is  a  similar  affection;  the  patient 
is  tortured  by  myriads  of  reflections  and  queries  about  commonplace 
matters.  The  prognosis  is  excellent,  two  patients  of  the  writer's  recover- 
ing completely  within  three  months,  and  without  the  change  of  scene 
which  proved  so  beneficial  in  Berger's  cases. 


312  INSANITY. 

was  suspended,  and  the  result  was  that  the  morbid  fear 
grew  fainter,  the  patient  began  to  resume  her  use  of  the 
various  articles  she  had  previously  dreaded  to  handle,  and 
even  went  out  on  the  street  alone  and  unveiled.  But  how 
much  deeper  the  disorder  may  lie  than  the  surface  symp- 
toms serve  to  indicate,  was  shown  by  this  case,  in  which, 
with  the  improvement  of  the  symptoms  for  which  the 
writer  was  consulted,  the  more  serious  ones  of  insane  man- 
nerism and  logical  perversity  which  to  the  laity  had  been 
less  noticeable  on  account  of  the  preponderance  of  the 
morbid  fears,  came  to  the  front. 

While  the  phases  of  monomania  just  described  may  be 
regarded  as  rudimentary  or  abortive  forms  of  that  malady, 
the  fundamental  disorder  may  be  as  great  as  in  delusional 
monomania,  if  we  may  infer  the  nature  of  the  cerebral  dis- 
order, at  present  undiscoverable  with  our  methods  of  ex- 
amination, from  the  somatic  anomalies  found  in  mono- 
mania sine  delirio,  and  in  monomania  with  imperative 
conceptions.  The  same  mal-configuration  of  the  skull,  as 
well  as  the  same  facial  expression  as  in  delusional  mono- 
mania, are  sometimes  found  in  cases  falling  under  the  head 
of  the  abortive  forms. 

Delusional  monomania  is  the  most  frequent  form  of  this 
disorder.  It  is  the  "  primare  Verriicktheit  mit  Wahn- 
ideen  "  *  of  the  Germans,  the  Wahnsinn  of  Snell,  and  the 
chronic  delusional  mania  of  some  English  and  American 
authors.  The  delusions  of  this  form  of  monomania  are 
alone  sufficient  to  characterize  this  disorder,  and  when 
found  serve  to  establish  the  diagnosis  ;  they  are  of  the  sys- 
tematized variety  (page  26). 

It  is  only  exceptionally  that  the  delusions  appear  ab- 
ruptly, and  those  appearing  in  this  way  constitute  connect- 
ing links  between  those  rudimentary  delusions  which  the 
writer  considers  the  imperative  conception  to  be,  and  the 
true  systematized  delusion.  Usually  unpleasant  visceral 
sensations,  hyperaesthesia  in  the  ano-genital  region,  strange 
sensations  flashing  up  from  the  latter  "through  the  spinal 
cord  to  the  brain"  (serving  as  the  basis  of  delusions  of 
sexual  congress  with  God,  devils,  or  men),  or  a  feeling  of 
dryness  in  the  throat  or  a  bad  taste  in  the  mouth  (serv- 
ing as  the  basis  for  delusions  of  poisoning),  are  experienced, 

*The   adjective    "primare"   is    entirely    unnecessary.      There    is    no 
"secundare  Verriicktheit,"   although    this   term   has    been    applied   to  „ 
chronic  confusional  insanity.  /0"<"  <" '  w-  <'  d  ic    Sr./L'^  ^r^o/^!^)  ^uz^t'^'--'-^ 


MONOMANIA,   ITS   COURSE   AND   VAklETIES.        313 

and  the  patient,  in  endeavoring  to  account  for  them,  builds 
up  his  insane  belief.  Sometimes  hallucinations  or  dreams 
contribute  additional  material. 

Usually  the  outbreak  of  the  disorder  coincides  with  some 
one  of  the  physiological  periods,  such  as  puberty,  the 
second  climacteric,  pregnancy,  and  the  puerperal  state.  It 
is  sometimes  precipitated  by  sexual  excesses,  more  fre- 
quently by  masturbation,  and  occasionally  by  visceral  dis- 
eases and  fevers.  Its  development  is  usually  gradual,  and 
is  comprised  in  the  progressively  firmer  and  more  extensive 
organization  of  the  delusions.  Sometimes  this  advance  is 
by  fits  and  starts. 

Delusions  of  persecution  are  the  most  common  ones  in 
delusional  monomania.  There  is  a  marked  difference  be- 
tween these  delusions  and  the  delusions  of  persecution 
found  in  melancholia.  While  the  melancholiac  believes 
that  he  is  pursued  or  punished  because  he  is  a  weak,  cow- 
ardly, bad,  or  criminal  person,  the  monomaniac  believes 
that  he  is  persecuted  from  motives  of  envy,  and,  as  a  rule, 
he  develops  exalted  delusions  of  his  personal  importance 
or  worth  side  by  side  with  those  of  persecution.  The 
dread  of  his  persecutors  may,  however,  throw  the  mono- 
maniac into  as  violent  and  dangerous  a  frenzy,  howbeit 
of  a  different  kind,  as  the  melancholiac.  Hallucinations, 
particularly  of  hearing,  which  are  very  common,  which  may 
be  limited  to  mere  "voices,"  or  consist  of  distinct  sen- 
tences, precipitate  the  explosion  of  these  episodical  deliria. 
Thus  Dubourque,  the  "Fourteenth-Street  assassin,"  who 
had  inherited  from  his  father  the  malformed  cranium  and 
insane  expression  of  a  monomaniac,  as  well  as  the  delusion 
that  an  uncle  had  died  leaving  him  several  millions  of  dol- 
lars, which  were  withheld  by  the  Government  of  the  United 
States,  had  heard  as  a  child  that  the  neighbors  proposed 
poisoning  him,  the  heir  to  this  great  estate.  While  at  work 
painting  a  transatlantic  steamer,  after  his  father's  death,  he 
heard  remarks  by  his  fellow-workmen  to  the  effect  that,  now 
that  the  older  claimant  was  dead,  they  would  waylay  him 
that  night  and  thus  exterminate  the  family  of  heirs.  On 
three  occasions  he  stabbed  persons  who,  he  alleged,  were 
pursuing  him  and  crying  out  to  kill  him  on  the  street. 
On  the  second  occasion  he  had  stabbed  a  police  officer. 
On  the  first  he  told  such  a  plausible  story  of  an  assault  and 
his  earnestness  of  manner  was  so  impressive  that  the  police 
magistrate  before  whom  he  was  brought  discharged  him. 


314  INSANITY. 

On  the  last  occasion,  in  broad  daylight,  he  was  passing 
through  a  crowd  of  ladies  on  Fourteenth  Street  who  were 
out  "shopping"  in  that  thoroughfare.  The  expression, 
attitude,  and  walk  of  the  man  were  such  that  many  of  the 
passers-by  avoided  him.  Suddenly  he  drew  a  compass,  such 
as  is  used  by  artists,  and  began  stabbing  right  and  left.  It 
is  not  known  how  many  persons  he  stabbed,  but  three 
women  were  dangerously  and  one  was  fatally  wounded.  To 
the  writer,  who  examined  him  at  the  request  of  the  district 
attorney,  he  said  that  from  all  sides  he  heard  the  cry, 
"There  goes  the  man  who  is  going  to  take  all  that  money 
out  of  the  land;  he  is  going  next  week.  Kill  him!"  and 
that  then  he  had  drawn  his  weapon  to  defend  himself.* 


No  better  example  of  the  insane  expression  could  be 
selected  than  that  of  this  subject  of  monomania  of  persecu- 
tion.    (Fig.  if.) 

The  beliefs  of  monomaniacs  are  almost  as  numerous  as 
the  patients.  They  are  all  characterized  by  this  feature, 
that  the  occurrences  in  the  outer  world  are  anxiously  ex- 
amined by  the  patient  with  a  view  of  tracing  their  connec- 
tion with  himself.  Accidental  remarks  by  others,  initials 
in    the   personal  columns  of  the  daily  papers,  bill-posters, 

*  He  shammed  amnesia  of  the  occurrence  at  first. 


MONOMANIA,    ITS   COURSE   AND   VARIETIES.        315 

biblical  passages,  and  certain  phrases  in  sermons  are  inter- 
preted as  having  special  reference  to  him.  Sometimes  a 
mere  exclamation,  coughing,  sneezing,  or  the  turning 
around  of  a  person  on  the  street,  are  supposed  to  be  sig- 
nals by  which  the  patient's  enemies  recognize  each  other. 
He  believes  that  he  is  ridiculed  ;  that  the  clergy  point  at 
him  for  the  purpose  of  degrading  him  in  the  eyes  of  his 
fellow-men  ;  that  he  is  accused  of  unnatural  or  foul  crimes, 
and  that  persons  on  the  street  hoot  at  him  and  are  em- 
ployed to  do  this  by  detectives,  free-masons,  Jesuits,  or 
their  business  and  professional  rivals.  If  an  official,  he 
suspects  his  subordinates  or  colleagues  of  putting  com- 
promising letters  among  his  papers,  with  the  intention  of 
intriguing  him  out  of  his  position.  The  result  is  that  these 
patients  are  involved  in  conflicts  with  the  authorities,  bring 
libel  suits  or  claim  rewards  for  unearthing  conspiracies 
which  they  believe  were  directed  against  their  superiors 
and  themselves  conjointly.  For  the  tendency  to  seek  the 
protection  of  courts,  or  to  punish  their  real  or  supposed 
foes  through  them,  the  Germans  have  devised  the  term 
querulous  monomania*  As  Krafft-Ebing  says,  these  patients 
are  defective  in  their  ethical  qualities;  their  alleged  posses- 
sion of  a  sense  of  right,  which  they  emphasize  on  all  occa- 
sions, is  in  reality  reducible  to  a  tremendous  egotism  which 
allows  them  to  recognize  in  law  only  a  means  to  their  per- 
sonal ends.  The  subjects  of  querulous  monomania  are 
early  remarkable  for  their  obstinacy,  their  tendency  to  in- 
terfere in  the  affairs  of  others,  and  their  impatience  of 
contradiction.  Involved  in  a  lawsuit  through  some  extrava- 
gant claim  or  supposed  sense  of  injury,  they  become  seized 
with  a  perfect  furor  for  litigation,  buy  books  of  law,  and 
may  become  even  well  versed  in  the  details  of  that  science. 
Defeated  in  one  court,  they  will  try  another,  and  appeal 
again  and  again.  Such  persons  are  well  known  in  several 
of  the  courts  of  this  city,  and  usually  treated  as  harmless 
lunatics.  But  they  do  not  all  sink  into  the  quiet  state  so 
finely  exhibited  by  an  old  lady  who  some  years  ago  was  a 
sojourner  at  the  surrogate's  court  of  this  city,  and  regu- 
larly handed  a  document  to  the  clerk,  to  have  it  as  regu- 
larly returned.  Some,  infuriated  at  their  failures,  become 
convinced  that  the  judges  are  bribed  or  under  the  advice  of 

*  "  Querulanten-Wahnsinn;"  "  Irrsein  der  Querulanten  und  Prozess- 
kramer." 


3l6  INSANITY. 

secret  societies,  and  they  resort  to  invectives  and  libels, 
send  lengthy  documents  to  the  press,  or  even  make  as- 
saults on  their  supposed  opponents  and  their  agents. 

Sometimes  hallucinations  and  illusions  preponderate  in 
the  mental  sphere  of  the  depressive  monomaniac.  He  hears 
a  thousand  foes,  feels  scorpions  and  parasites  crawling 
around  him,  which  have  been  let  loose  by  his  destroyers, 
he  tastes  poison,  blood,  the  flesh  of  corpses  in  his  food,  and 
there  are  concealed  foes  or  animals  in  his  intestines. 
Women  generally  complain  of  being  raped,  others  of  accusa- 
tions made  against  them  affecting  their  chastity;  and  men,  as 
in  one  case  of  the  writer's,  complain  that  their  foes  are  draw- 
ing out  their  semen  through  the  nose  by  an  invisible  in- 
fluence in  the  shape  of  an  "ascending  vapor."  Where  the 
delusions  assume  this  character,  and  relate  to  bodily  states, 
the  designation  hypocJiondriacal  monoviania  is  applicable.  A 
most  interesting  instance  of  this  variety  is  that  on  which 
the  mediaeval  belief  that  there  was  a  "wandering  Jew"  was 
based.  At  various  periods  (as  it  happened,  about  once  a 
century)  persons  appeared,  wandering  anxiously  from  place 
to  place,  asserting  and  believing  that  they  were  this  myth- 
ical personage.  In  a  French  asylum  two  hypochon- 
driacal monomaniacs  were  observed  who  entertained  the 
same  belief,  which  arose  in  this  way  :  One  organ  after 
another  was  suspected  to  be  the  seat  of  a  fatal  disease;  the 
patients,  believing  that  these  diseases  should  naturally  have 
terminated  their  existence,  came  to  the  conclusion  that  they 
were  not  mortal  ;  but,  as  the  only  human  being  not  mortal 
and  still  on  this  earth  was  supposed  by  them  to  be  the 
wandering  Jew,  they  believed  themselves  to  be  necessarily 
identical  with  him. 

A  remarkable  phenomenon,  and  one  bearing  out  the 
statements  of  the  last  chapter  as  to  the  essential  sameness  of 
all  the  monomanias,  is  what  Krafft-Ebing  designates  as 
the  transformation  of  the  disorder  ;  namely,  a  rapid  and 
sometimes  sudden  change  of  the  delusions  of  persecution 
into  those  of  aggrandizement.  This  transformation,  un- 
like that  occasionally  observed  in  paretic  dementia 
(p.  200),  which  is  without  logical  motive,  is  the  result 
of  inward  reflection  and  reasoning.  The  patient,  who  has 
been  all  along  depressed  because  of  the  machinations  of  his 
foes,  now  concludes  that  he  is  a  person  of  some  importance, 
and  may  even  take  a  delight  in  his  martyrdom  within  the 
walls  of  an  asylum.     He  believes  himself   to  be   a  king,   a 


MONOMANIA,    ITS   COURSE   AND   VARIETIES.        317 

prophet,  or  a  religious  and  social  reformer.  Occasionally 
an  intermediate  trance-like  or  ecstatic  state  is  observed  ;  or 
the  patient,  who  interpreted  the  glances  of  people  on  the 
street  as  inimical,  now  notices  an  approbation  or  admiration 
in  their  looks  and  expressions,  and,  instead  of  the  attacks, 
sneers,  and  libels  previously  detected  in  the  daily  papers 
and  on  bill-posters,  he  discovers  obscure  hints  as  to  his 
great  services  to  the  state,  his  birthright  to  the  throne,  or  to 
some  great  estate  in  them. 

That  variety  of  monomania  which  is  characterized  by 
the  erotic  delusions  already  described  in  the  chapter  on 
delusions  (page  27)  is  termed  erotic  monoinania.  While  the 
ideas  of  the  patient  are  in  the  main  expansive  and  quix- 
otic, yet  ideas  of  persecution  may  be  developed,  in  conse- 
quence of  the  failure  to  accomplish  the  platonic  union  with 
the  adored  object,  the  ridicule  by  his  relations  and  friends, 
or  the  incarceration  in  an  asylum  rendered  necessary  by  his 
extravagant  behavior. 

One  variety  of  expansive  monomania,  which  is  un- 
doubtedly becoming  rarer,  is  that  denominated  religious 
monomania.  The  patients  exhibiting  this  form  usually 
manifest  a  certain  degree  of  weak-mindedness  or  imbecility 
in  childhood.  The  misconception  of  religious  instruction, 
or  the  misinterpretation  of  sermons,  particularly  of  such  as 
are  delivered  by  popular  pulpit  orators,  leads  them  to  the  de- 
velopment of  a  pseudo-religious  and  sometimes  of  a  fervid 
religious  enthusiasm.  The  occurrence  of  any  of  the  dis- 
appointments or  hard  blows  incident  to  life  leads  to  their 
complete  self-abandonment  to  religious  speculation  and  the 
perusal  of  religious  works.  Ecstatic  and  visionary  states 
then  occur,  and  the  delusion  may  develop  of  being  the 
mother  of  God,  of  Christ,  or  of  All  Saints.  Hallucinations 
are  frequent :  the  gates  of  heaven  are  seen  ajar,  processions 
of  angels  singing  anthems,  the  Virgin  Mary  beckoning, 
God  pointing  out  "  his  faithful  son,"  or  "  daughter,"  as 
which  the  patient  considers  himself  or  herself,  are  seen 
within  them.  Often  depressive  ideas  develop,  due  to  hal- 
lucinatory visions  of  devils  and  tempting  or  taunting 
voices.  The  devil  is  then  supposed  to  fill  the  apartment 
of  the  devotee  with  noisome  smells,  to  repeat  the  tempta- 
tions of  St.  Anthony,  or  to  select  some  one  of  the  viscera 
of  the  patient  as  the  site  of  his  operations  against  his  health 
and  happiness.  Usually  the  patient,  who  about  this  time 
develops  ideas  of  self-exaltation,  claims  to  have  triumphed 


3l8  INSANITY. 

over  the  arch-enemy,  and  then  proposes  to  proceed  to 
aggressive  measures  against  him  and  his  servants  on  earth. 
More  than  one  insane  fanatic  of  the  middle  ages  has  been 
responsible  for  the  fierce  campaigns  waged  against  dissenters 
and  alleged  infidels,  and  not  one  of  the  least  remarkable  in- 
cidents of  this  period  of  history  is  the  fact  that  for  two 
centuries  Europe  poured  out  its  best  strength  in  the  cru- 
sades, under  the  influence  of  the  prayers,  sermons,  and 
visions  of  a  Peter  the  Hermit,  who  undoubtedly  suffered 
from  this  form  of  monomania. 

Sexual  ideas  are  common  in  religious  monomania.  The 
male  patients  believe  that  female  seducers  are  sent  to  them 
at  night  by  Satan  ;  the  female  ones,  that  they  are  pregnant 
by  God  or  some  other  sacred  personage. 

The  chief  danger  from  these  patients  lies  in  the  fact  that 
they  often  suffer  from  the  hallucination  of  hearing  the  com- 
mands of  God  to  do  certain  things.  It  is  in  obedience  to 
such  commands  that  religious  monomaniacs  have  com- 
mitted homicide,  suicide,  or  self-mutilation.  A  remarkable 
instance  is  that  of  Matthieu  Louvat,  who  crucified  himself 
in  obedience  to  such  a  command. 

The  prognosis  of  monomania  is  very  unfavorable.  The 
chief  feature  to  be  consulted  in  reference  thereto  is  the 
mental  power  of  the  patient.  The  more  considerable 
this  is,  the  more  likely  is  a  correction  of  the  delusive  be- 
liefs, the  delusive  suspicions,  or  mOrbid  fears  to  take  place. 
Consequently  the  prognosis  is  best  with  those  patients  who 
suffer  from  simple  delusions  of  persecution  or  of  social 
ambition,  worse  with  erotomania,  and  worst  of  all  with  re- 
ligious monomania,  for  here,  as  has  been  already  stated,  a 
background  of  original  weak-mindedness  is  generally  pres- 
ent. Bad  as  the  prognosis  is  in  this  form,  cases  are  re- 
ported where  the  hallucinations  and  delusions  disappeared, 
and  the  patient,  if  not  altogether  recovering,  showed  noth- 
ing abnormal  beyond  an  extravagant  religious  zeal  and  a 
<lesire  to  convert  mankind  to  what  he  happened  to  consider, 
in  the  excessive  egotism  of  the  fanatic,  the  right  faith.  An 
instance  of  well-nigh  complete  recovery  is  that  of  the  author 
of  Pilgrim's  Progress.  In  his  case  as  in  the  few  others  in 
which  relative  recovery  ensued,  hallucinatory  phenomena 
were  in  the  foreground  and  logical  perversion  in  the  back- 
ground. 

Monomania,  when  not  cured,  remains  stationary  for 
years.     The  logic  of   unrecovered   patients   becomes  more 


MONOMANIA,   ITS   COURSE   AND   VARIETIES.        319 

perverse,  they  are  more  frequently  found  in  abstracted  rev- 
eries than  in  the  earlier  periods  of  the  disorder;  but  mental 
deterioration  does  not  proceed  rapidly,  and  never  reaches 
the  degree  of  chronic  confusional  insanity  or  of  terminal 
dementia,  unless  there  is  some  inter-current  disease.  A 
condition  similar  to  chronic  confusional  insanity  developed 
in  consequence  of  an  attack  of  cerebral  haemorrhage  in  a  pa- 
tient shown  the  writer  by  Dr.  T.  A.  M'Bride.  In  two  cases  in 
private  practice,  and  in  two  in  the  pauper  asylum,  the  com- 
plication of  monomania  by  paretic  dementia  (see  "  Diag- 
nosis"), first  noticed  by  Hostermann,  was  observed  by  the 
writer.  In  such  cases  the  paretic  dementia  is  a  genuine 
complication,  and  not  a  true  terminal  state  of  monomania. 
Any  of  the  ordinary  forms  of  insanity,  mania,  or  melan- 
cholia, may  occasionally  complicate  the  case  and  the  diag- 
nosis for  the  moment,  just  as  any  acute  affection  may 
occur  in  subjects  suffering  from  chronic  constitutional  com- 
plaints, and  mask  them  for  the  time  being. 


PART  III. 
INSANITY  IN  ITS  PRACTICAL  RELATIONS. 


CHAPTER  I. 

How  TO  Examine  the  Insane. 

We  will  suppose  that  the  physician  is  called  to  see  a  person 
whom,  from  the  previous  history  or  the  expressed  suspicion 
of  the  relatives,  he  considers  it  necessary  to  investigate 
the  mental  state  of.  In  such  a  case  he  should  bear  the  fol- 
lowing prominently  in  mind:  The  majority  of  the  insane 
are  either  communicative,  or,  if  not  communicative,  readily 
betray  their  insanity  by  their  physical  appearance,  and  it  is 
best  in  the  interests  of  such  patients  for  the  physician  to 
visit  them  in  his  actual  capacity  as  a  medical  adviser.  On 
the  other  hand,  there  are  certain  of  the  insane  who  are 
skilful  dissimulators,  whom  the  most  expert  alienist  might 
fail  to  unravel  the  real  mental  state  of  at  any  single  exami- 
nation, and  who  would  be  put  on  their  guard  or  led  to  the 
commission  of  dangerous  acts  by  the  announcement  that  a 
physician  was  approaching.  It  may  be  necessary  in  such 
exceptional  cases  for  the  physician  to  visit  the  patient  as  if 
casually,  or  even  to  conceal  his  real  character.* 

*  He  who  has  been  in  that  emergency  to  which  asylum  physicians,  with 
attendants  and  other  conveniences  at  their  disposal,  are  rarely  liable,  of 
single-handed  encounters  with  homicidal,  treacherous,  and  cunning  luna- 
tics, fully  aware,  as  some  of  them  are,  of  their  legal  irresponsibility,  can 
have  but  a  smile  for  the  injunction  never  to  resort  to  "deception" — as  it 
is  called — with  the  insane.  Nor  is  it  easy  to  draw  the  distinction  between 
the  ordering  an  attendant  to  watching  a  suspected  simulator  through  a 
window,  or  a  crevice,  a  procedure  resorted  to  time  and  again  by  the  best 
French  and  German  alienists,  and  the  visiting  of  such  persons  by  the 
more  competent  alienist  himself  in  a  character  calculated  to  throw  the 
simulator  as  well  as  the  dissimulator  off  his  guard,  and  to  reveal  that 
truth  which  it  may  be  desirable  to  establish  in  the  interests  of  justice,  or 


HOW   TO    EXAMINE   THE    INSANE.  32I 

The  first  step  in  the  examination  of  an  alleged  lunatic  is 
the  study  of  his  features,  manner,  and  attitude.  In  some 
of  the  insane  these  will  not  betray  the  mental  state;  in  the 
majority,  however,  they  afford  such  significant  indications 
of  the  insanity,  that  the  expert  alienist  may  arrive  at  a  pro- 
visional and  approximate  opinion  of  the  form  of  insanity 
with  which  he  has  to  deal,  and  thus  be  able  to  adopt  a  spe- 
cial line  of  examination  by  the  inspection  of  the  patient 
alone. 

It  is  very  unwise,  however,  for  the  physician,  on  entering 
a  room  filled  with  people,  to  walk  directly  up  to  the  person 
whom,  from  his  appearance,  he  suspects  to  be  the  patient, 
and  to  proceed  brusquely  with  the  examination.  He  may 
be  right  in  his  selection,  and  accomplish  his  possible  object 
of  impressing  the  laity  with  his  diagnostic  skill.  But  if  the 
patient  should  happen  to  be  suffering  from  a  form  of  insan- 
ity of  a  hypochondriacal  or  depressive  character,  the  pro- 
cedure would  have  a  bad  effect  on  him.  The  patient  might, 
if  hypochondriacal,  argue  that  there  must  be  some  truth  in 
his  hypochondriacal  belief,  inasmuch  as  a  stranger,  on  first 
sight,  picked  him  out  as  the  patient;  while  he  who  is  suffer- 
ing from  delusions  of  persecution  might  discover  new  build- 
ing material  for  the  delusion  that  there  was  a  conspiracy 
against  him  in  his  recognition  by  a  person  who  had  never 
seen  him  before.  On  the  other  hand,  there  is — even  with 
an  extensive  experience — a  chance  of  committing  an  error. 
An  experienced  alienist,  who,  in  almost  every  case,  had  been 
able  to  pick  out  the  insane  member  of  the  family  he  was 
called  upon  to  visit — wherever  he  saw  fit  to  make  the  at- 
tempt— picked  out  the  imbecile  brother  of  the  patient  as 
the  lunatic.  It  is  true  that  there  was  a  far  more  serious 
congenital  mental  defect  in  that  brother  than  in  the  patient 
whom  it  was  proposed  to  have  him  examine;  but,  as  the 
latter  suffered  from  an  acute  psychosis,  which  had  led  to  a 
suicidal  attempt,  this  was  not  appreciated,  and  the  alienist 
might  have  been  supposed  to  have  blundered.  A  source 
of  many  possible  mistakes  is  the  fact  that,  in  case  of  insan- 

at  least  of  the  individual.  It  so  happens  that  the  recent  demonstrative 
sneering  at  the  procedure  here  advocated  has  been  by  members  of  a  circle 
composed  of  men  who  could  readily  afford  to  disregard  the  most  legiti- 
mate methods  of  investigation,  because  their  testimony  is  rarely  regulated 
by  the  demands  of  medical  truth,  but  who  have  themselves  unfortunately 
resorted  to  unworthy  subterfuges,  such  as  taking  part  in  carousals  with  a 
paretic  dement  in  order  to  accomplish  his  commitment  to  an  asylum. 


322  INSANITY. 

ity  dependent  upon  a  transmitted  taint,  other  members  of 
the  family  than  the  one  concerning  whom  the  physician  is 
consulted  may  present  peculiarities  in  behavior  and  ap- 
pearance suggesting  the  existence  of  insanity,  or  of  the  in- 
sane disposition.  This  has  frequently  been  the  writer's 
experience. 

In  proceeding  to  examine  a  patient  the  physician  will  be 
guided  in  great  part  by  the  expression  of  his  countenance, 
his  manner,  and  the  first  words  spoken  if  he  talks  sponta- 
neously. It  is  obvious  that  his  own  demeanor  must  be  very 
different  with  various  forms  of  insanity.  Inlieed  it  would 
be  absurd  to  attempt  to  follow  any  fixed  rule  of  conduct; 
though,  as  a  general  thing,  it  is  well  not  to  appear  searching 
or  anxious  in  the  examination  of  any  alleged  lunatic,  nor  to 
give  the  impression  that  the  examiner  is  particularly  inter- 
ested in  the  mental  features  of  a  suspicious  one. 

If  the  patient's  countenance  expresses  distrust  or  suspi- 
cion, it  is  well  to  delay  the  examination  until  he  becomes 
somewhat  accustomed  to  the  physician's  presence.  Some- 
times on  arriving  at  the  patient's  residence  the  physician 
will  find  him  held  by  others  or  tied  down.  In  the  majority 
of  cases,  the  physician  can  risk  sending  the  restraining  ap- 
paratus and  the  holding  persons  (whom  the  patient  often 
confounds  with  his  supposed  enemies)  out  of  the  room  ;  a 
step  which  if  feasible,  will  facilitate  the  further  examina- 
tion by  gaining  the  patient's  confidence.  In  case  the  in- 
sanity is  of  a  violent  and  dangerous  type  this  procedure 
will  not  be  necessary,  for  the  actions  and  words  of  the 
patient  will  then  establish  the  diagnosis  sufficiently  well  for 
all  immediate  purposes,  and  as  well  as  any  single  examina- 
tion is  calculated  to  do. 

A  large  number  of  patients  whom  the  alienist  is  called 
upon  to  examine  are  not  apt  to  be  communicative  to  a 
stranger  at  first.  And  nothing  would  defeat  the  purposes 
of  the  examination  so  certainly  as  an  immediate  cross- 
questioning  with  regard  to  mental  symptoms.  Frequently 
the  patient  apprehends  that  he  is  considered  insane,  oc- 
casionally even  is  himself  convinced  of  his  insanity;  but  he 
is  as  little  desirous  of  being  pronounced  insane  as  an  ordi- 
nary patient  in  private  practice  would  be  to  have  the  exist- 
ence of  a  gonorrhoea  or  a  chancre  revealed  in  the  presence 
of  his  family.  In  all  such  cases  one  fact  comes  to  the  phy- 
sician's aid,  namely,  that  the  insane  as  a  rule  are  deficient 
in  concentration  power  and  in  self-control,  and  that    how- 


HOW   TO   EXAMINE   THE   INSANE.  323 

ever  firmly  they  may  have  resolved  not  to  reveal  their 
thoughts,  yet  a  prolonged  examination  will  evoke  involun- 
tary admissions,  which,  once  secured,  enable  him  to  reach 
the  very  centre  of  the  mental  citadel.*  He  must  conse- 
quently approach  him  by  a  circuitous  line,  and  there  is  one 
which,  in  his  character  as  a  physician,  he  may  follow  without 
arousing  the  suspicions  of  the  patient,  or  resorting  to  a 
subterfuge,  namely,  that  of  an  examination  of  his  physical 
state.  Indeed  this  is  itself  sometimes  calculated  to  reveal 
important  facts  ;  few  patients  will  suspect  that  an  examina- 
tion of  the  tongue  can  refer  to  their  mentality,  although  a 
fibrillary  tremor  or  deviation  of  that  muscle  may  prove  of 
great  signification  to  the  physician.  The  existence  of 
visceral  disturbance,  of  disordered  sensations  and  pains, 
and  of  imaginary  complaints  in  some  of  the  insane 
renders  them  very  willing  to  be  examined  on  these  points. 
The  transition  from  questions  relating  to  visceral  trouble 
to  inquiries  about  the  patient's  sleep  is  an  easy  and  natural 
one,  and  appears  legitimate  even  to  the  most  suspicious 
lunatic.  If  the  sleep  is  admitted  to  be  disturbed  the  pa- 
tient may  make  avowals  which  suggest  the  existence  of 
hallucinations,  and  the  character  of  these  symptoms  will 
often  alone  suffice  to  reveal  the  nature  of  the  insanity.  In 
other  cases  a  few  judicious  inquiries  as  to  business  or 
family  troubles,  made  on  the  assumption  (on  the  patient's 
part)  that  these  may  bear  a  causal  relation  to  his  physical 
disorder,  will  sometimes  lead  to  "  confidential  "  communica- 
tions as  to  alleged  conspiracies,  antipathies,  attempts  by 
others  to  poison  his  food,  marital  infidelity,  the  ruin  of  his 
fortune,  the  commission  of  some  crime,  or  of  the  fact  that 

*  This  the  following  conclusion  of  a  dialogue  illustrates  : 

Q.  What  is  it  that  kept  you  awake  last  night? 

A.  I  heard  voices  telling  me  that  I  was  a  bad  woman  for  suspecting 
my  husband. 

Q.  What  did  you  suspect  your  husband  of? 

A.   (Obstinate  mutism.) 

Q.  What  made  you  say  that  your  husband  was  a  bad  man,  and  went 
with  other  women,  as  well  as  the  other  things  you  said  about  God? 

A.  I  am  compelled  to  say  those  things  against  my  will.  I  do  not  be- 
lieve that  he  is  a  bad  man. 

Q.  Oh  I  see  !     You  do  not  think  these  things  are  true — 

A.  Do  I  [getting  excited].  Why  they  are  revelations  !  God  speaks 
through  me.  [Here  the  patient  burst  out  in  delusional  vituperation 
against  her  husband,  and  although  quiet  and  reserved  up  to  that  time,  de- 
veloped a  delirious  flight  of  ideas  of  a  combined  expansive  and  perse- 
cutory kind.] 


324  INSANITY. 

he  is  unable  to  feel  for  his  family  as  of  yore.  As  soon  as  a 
patient  has  reached  this  point  the  ice  is  broken,  and  the 
mental  symptoms  may  be  elicited  in  abundance,  and  as 
soon  as  he  begins  to  reveal  his  mental  state  it  is  well  to  let 
the  patient  speak  without  interruption,  and  particularly  to 
avoid  asking  leading  questions. 

There  are  patients  whose  affections  for  their  relatives  are 
changed,  and  others  in  whom  the  affections  for  some  one  or 
other  or  all  the  members  of  their  family  are  unchanged. 
In  the  former  case  the  patient  will  be  more  communicative 
if  examined  by  himself  ;  in  the  latter  case  it  is  best  to 
havesomerelative,  in  whom  the  patient  has  confidence,  pres- 
ent. Frequently  the  presence  and  aid  of  the  family  phy- 
sician is  of  great  service  in  case  the  examination  is  made  by 
a  stranger.  But  even  where  it  is  found  advisable  to  con- 
duct the  examination  of  a  patient  alone,  it  is  well,  at  some 
time  in  its  course,  to  introduce  the  family,  and  study  his 
demeanor,  and  mark  his  sayings  when  confronted  with 
those  whom  he  may  regard  as  his  foes,  his  assassins,  or  his 
victims,  as  the  case  may  be. 

There  are  some  patients  who  are  really  anxious  to  be  ex- 
amined— not  for  the  mental  trouble,  which  they  ignore, — 
but  for  imaginary  visceral  disease.  This  is  particularly 
the  case  with  hypochondriacal  monomaniacs  and  paretic 
dements  with  hypochondriacal  delusions.  With  such  pa- 
tients the  examination  is  child's  play;  for  in  every  sen- 
tence they  reveal  their  mental  state,  and  spread  out  their 
delusions  unasked  before  the  physician. 

The  use  of  ph)^sical  appliances,  the  ophthalmoscope, 
sphygmograph,  sesthesiometer,  thermometer,  etc.,  must  be 
considered  from  two  points  of  view:  first,  their  actual  diag- 
nostic value;  second,  the  possible  effect  of  their  employ- 
ment on  the  patient's  mind.  In  paretic  dementia  and 
hypochondriacal  monomania,  for  example,  the  use  of  these 
instruments  paves  the  way  for  the  subsequent  mental  exam- 
ination. The  paretic  dement  shows  that  exaggerated  ap- 
preciation of  these  appliances  already  referred  to  (p.  194), 
while  the  hypochondriacal  patient  becomes  reassured  by 
the  thoroughness  of  the  examination  he  so  morbidly  craves. 
The  melancholiac  and  sufferer  from  persecutory  delusions 
may  have  his  fears  redoubled  by  the  mere  sight  of  these 
to  him  unfamiliar  and  mysterious  objects,  and  it  is  there- 
fore best,  if  the  instruments  of  precision  are  employed 
at  all  here,  to  use  them  at  the  close  of  the  examination. 


HOW   TO    EXAMINE   THE   INSANE.  325 

It  is  a  rule,  which  goes  without  saying,  that  no  deception, 
direct  or  indirect,  is  ever  justified,  unless  it  is  necessary  for 
the  good  of  the  patient,  the  interest  of  his  property,  and  the 
safety  of  his  family  and  of  society  at  large.  But  only  a 
pretender  or  one  unfamiliar  with  insanity  will  demand  that 
no  deception  should  ever  be  practiced.  If  a  patient  asks 
point  blank  whether  the  physician  proposes  to  take  him  to 
an  asylum,  and  who  it  is  that  has  requested  him  to  do  so, 
while  it  is  possible  that,  in  the  event  of  a  direct  answer,  the 
lunatic  may  take  steps  to  revenge  himself  on  a  member  of 
his  family,  it  would  be  tantamount  to  criminal  negligence 
to  give  a  so-called  "  truthful  "  answer.  Let  him  who  gives 
,  it  bear  the  consequences  !  It  is  best,  in  case  the  patient 
presses  the  question  of  what  the  physician  proposes  to  do, 
to  claim  time  for  reflection,  and,  when  all  necessary  steps 
are  arranged,  to  tell  him  the  entire  truth.  In  some  cases 
even  this  would  be  grossly  inhumane;  as,  for  example,  in  the 
case  of  a  paretic  dement,  whose  property,  being  already,  it 
is  to  be  presumed,  under  proper  guardianship,  and  he  being 
about  to  be  placed  where  he  can  harm  neither  himself  nor 
his  family,  may  be  permitted  to  linger  out  his  days  in 
dreamy  and  sometimes  comparatively  felicitous  uncon- 
sciousness of  his  dread  malady  and  impending  death  by  it. 

With  patients  who  are  hilarious,  such  as  exalted  paretic 
dements  and  maniacs,  it  is  well  for  the  physician,  although 
he  may  not  go  so  far  as  to  assume  the  character  of  a  "  hail 
fellow  well  met,"  to  pocket  for  the  time  being  the  stiffer 
variety  of  professional  dignity  if  among  his  "  accomplish- 
ments." These  patients  are  as  quick  to  form  dislikes  and 
antipathies  as  friendships  and  exaggerated  admiration. 
They  are  very  apt  to  entertain  as  exaggerated  a  contempt  for 
anything  that  smacks  of  what  they  may  regard  to  be  con- 
ceit, overbearing  pride,  and  aestheticism;  and  from  contempt 
to  a  demonstration  with  the  fists  the  transition  is  some- 
times very  rapid  with  them. 

There  is  an  idea  current  that  patients  can  be  stirred  up 
to  reveal  their  suspicions  and  beliefs  by  threats  and  prom- 
ises. There  are  very  few  lunatics  whom  the  physician  is 
likely  to  be  called  upon  to  examine  outside  of  the  asylum 
who,  if  not  in  a  stuporous  or  apathetic  state,  would  not 
resent  the  former  and  despise  the  latter.  It  is  a  mistake  to 
believe  that  a  lunatic  can  be  treated  altogether  like  a  child; 
his  perceptions  may  be  as  acute,  his  feelings  as  sensitive,  and 
his   pride   as  great  as   those  of   the  examiner.     It  is  with 


326  INSANITY. 

hysterical,  pubescent,  and  masturbatory  lunatics  only  that 
harsh  measures  are  sometimes  indicated  and  efficacious. 

Although,  under  exceptional  circumstances,  the  physician 
may,  of  his  own  choice,  consider  it  desirable  to  examine  an 
alleged  lunatic  without  previous  communication  with  other 
parties,  he  will  in  ordinary  practice  find  it  of  the  highest 
importance  to  obtain  a  history  of  the  patient  before  exam- 
ining him.  It  is  well  to  collate  all,  even  the  most  trivial, 
observations  made  by  the  laity,  before  seeing  the  patient; 
for  among  them  may  be  discovered  facts  which  in  the  sub- 
sequent examination  can  be  utilized  in  a  more  accurate 
analysis  of  the  case  than  the  best  examination  without 
them  could  furnish.  But  it  stands  to  reason  that  the  state- 
ments of  others  should  never  constitute  the  basis  for  an 
opinion  unless  the  physician  becomes  convinced  that  they 
are  consistent  with  the  results  of  his  own  observations  of 
the  patient. 

In  the  examination  of  the  patient's  facial  expression  and 
attitude  the  physician  should  include  that  of  his  dress  and 
surroundings.  Peculiarities  of  costume  when  found  may 
often  serve  as  a  basis  of  comment  and  inquiry,  revealing 
the  existence  of  morbid  projects  or  of  absurd  reasoning. 
On  one  occasion  the  writer,  on  entering  the  residence  of  a 
patient,  saw  little  square  patches  of  wall-paper  pasted  over 
different  parts  of  the  plastering  on  the  side  of  the  staircase. 
The  patient  was  very  taciturn,  but  the  inquiry  as  to  the  un- 
usual appearance  of  his  house  led  to  the  revelation  of  the 
fact  that  the  patient  believed  himself  ruined,  unable  to 
meet  the  expenses  of  plastering,  and  had  himself  taken 
scraps  of  paper  at  random  to  cover  up  cracks  and  defects 
in  the  ceiling  and  walls. 

Some  patients,  as  soon  as  the  ice  is  broken,  exhibit  docu- 
ments relating  to  their  morbid  ideas,  which  often  serve 
to  portray  the  nature  of  their  illness  better  than  any  verbal 
inquiry.  To  study  these  is  hence  of  the  highest  import- 
ance. With  the  chronic  insane  it  is  well  to  induce  the  pa- 
tient to  reveal  the  contents  of  his  pockets.  In  some  cases 
the  physician  will  find  that  scraps  of  string,  tin-foil,  and 
rubbish  are  accumulated  without  any  special  idea ;  this 
usually  indicates  deterioration.  In  a  few,  alleged  pres- 
ervatives against  the  assaults  of  demons  and  imaginary 
foes  are  found,  and  questioning  reveals  the  delusion  which 
has  caused  the  patient  to  provide  himself  with  them.  A 
large    number  of   patients  carry  their   insane   documents 


HOW   TO    EXAMINE   THE   INSANE.  327 

about  with  them,  and  these  are  hence  obtainable  by  a  per- 
sonal search,  which,  as  a  rule,  the  patient  assists  in,  or  sub- 
mits to  willingly. 

In  tracing  out  a  morbid  idea  the  physician  must  not 
content  himself  with  "  drawing  out  delusions,"  as  a  super- 
ficial writer  advises,  under  the  erroneous  idea  that  the  ex- 
istence of  a  delusion  is  satisfactory  and  sufficient  proof  of 
insanity.  Any  asylum  attendant  of  experience  would  be 
an  expert  on  insanity  if  this  were  so.  The  true  alienist  will! 
always  remember  that  he  has  an  intricate  mental  mechan- 
ism to  analyze,  and  that  however  much  that  mechanism 
may  be  disturbed,  no  examination  from  any  one-sided 
point  of  view  will  suffice  to  reveal  the  character  of  the  dis- 
turbance. It  is  not  the  patient's  ideas  so  much  that  he  is 
concerned  with  as  the  manner  in  which  they  have  arisen 
and  are  nursed  by  the  patient.  Let  him  therefore  carefully 
watch  his  method  of  reasoning,  and  bear  in  mind  that  those 
patients  who  consent  to  communicate  any  of  their  thoughts 
are  usually  so  preoccupied  with  the  morbid  ones  that  they 
are  only  too  glad  to  get  a  listener,  and  when  they  have  one, 
prefer  a  patient  listener  to  one  who  gossips.  There  is  no 
surer  means  of  making  patients  conceal  their  delusions  than 
the  ridicule  to  which  some  examiners  resort  with  the  ob- 
ject of  "drawing  them  out."  No  delusion  was  ever  cured 
or  discovered  by  ridicule;  but,  on  the  contrary,  delusions 
are  sometimes  thereafter  fortified  and  obstinately  con- 
cealed. It  may,  however,  be  very  well  to  express  sur- 
prise at,  or  to  affect  not  to  understand  certain  minor  fea- 
tures of  the  patient's  statements,  and  thus  to  induce  a  fuller 
explanation,  and  to  test  his  reasoning  and  recollecting  power. 
It  is  particularly  desirable  to  have  him  go  over  the  ground 
twice,  to  note  inconsistencies  in  the  two  stories,  to  bring 
these  to  his  attention,  with  the  purpose  of  testing  his  mem- 
ory as  well  as  the  systematization  of  his  ideas.  In  case  any 
one  present  at  the  examination  ridicules  the  patient  it  will 
materially  facilitate  the  inquiry  and  gain  the  patient's  con- 
fidence to  reprove  such  a  person,  or  to  send  him  out  of  the 
room. 

In  the  case  of  patients  who  are  reluctant  to  be  examined 
it  will  often  be  found  of  service  to  turn  the  conversation  on 
recent  events  of  importance  to  the  patient,  his  family,  or  to 
such  of  a  sensational  and  political  character.  It  will  be 
not  unfrequently  found  that  the  morbid  ideation  or  morbid 
emotional  condition  of  the  mind  is  connected  with  some 


328  INSANITY. 

important  event  in  the  patient's  career,  such  as  marriage, 
divorce,  financial  gains  and  losses,  and  new  business  under- 
takings. In  other  cases,  prominent  political  events,  relig- 
ious revivals,  and  temperance  movements  will  be  found  to 
furnish  the  keynote  to  the  patient's  mental  state. 

Much  has  been  said  about  the  necessity  of  verifying  de- 
lusions: a  popular  writer,  as  well  as  his  plagiarists,  have  laid 
great  stress  on  the  necessity  of  finding  out  whether  there 
may  not  be,  after  all,  a  substantial  basis  for  the  patient's  ideas. 
While  it  is  well  to  always  do  this  for  other  reasons,  particu- 
larly in  cases  where  an  examination  is  necessarily  hurried,*  or 
where  the  physician  anticipates  the  possibility  of  having  to 
defend  his  opinion  before  a  non-expert  jury,  it  may  be 
stated  right  here  that  he  who,  after  a  careful  examination 
of  the  patient,  requires  such  an  examination  of  his  circum- 
stances to  find  out  whether  he  is  insane  or  not  is  simply 
not  an  alienist.  Repeatedl}'  does  it  occur  in  the  alienist's 
experience  that  the  facts  of  a  case  and  the  delusion  happen 
to  correspond.  Thus  a  salacious  woman  may  be  actually 
unfaithful  to  an  impotent  and  inebriated  husband,  who  en- 
tertains the  suspicion  of  marital  infidelity.  But  that  sus- 
picion is  nevertheless  a  delusion,  because  the  patient  cannot 
give  the  reasons  for  his  belief  as  a  sound  person  would,  nor 
reason  logically  on,  and  react  normally  to  it.  He  also  ex- 
hibits a  tendency,  common  to  the  insane,  of  attributing  to 
everything,  whether  trivial  or  of  magnitude,  some  relation 
to  himself.  This  selfish  tendency,  using  the  adjective  in  its 
widest  sense,  is  one  of  the  distinguishing  features  of  insane 
ideas.  An  acute  maniac  claimed  that  people  had  put  a 
rope  under  her  bed  ;  this  was  true.  She  added  that  it  was 
for  the  purpose  of  hanging  her  that  night ;  which  was  in- 
sane.    A  person  of  sound  mind,  if  annoyed  by  the  idea  of 

*  An  instance  of  the  risks  assumed  in  making  a  "snap  diagnosis"  is 
the  following.  The  writer,  being  belated  at  his  clinic,  and  having  about 
half  a  minute  to  look  over  the  patients  to  be  introduced  to  the  class  and 
examined  by  the  students,  had  a  slightly  intoxicated  man  brought  to 
him,  who  complained  of  poisoned  wounds,  and  spoke  of  lions  and  tigers. 
His  speech  was  thick  as  a  result  of  continued  libations.  The  writer  sus- 
pected that  it  was  a  case  of  alcoholism  with  hallucinations  and  delusions, 
and  anticipated  having  a  good  opportunity  for  illustrating  some  im- 
portant points.  Before  the  class,  when  a  more  careful  examination  was 
made,  it  was  found  that  the  patient,  while  addicted  to  spirituous  liquors, 
was  the  trainer  of  the  lions  and  tigers  of  one  of  the  large  circus  shows, 
and  had  actually  been  seized  and  mangled  by  a  tiger,  showing  the  severe 
wounds  made  by  the  animal,  which,  as  is  frequently  the  case  with  the 
tiger's  bite,  had  been  of  a  poisonous  character. 


HOW   TO    EXAMINE   THE   INSANE.  329 

a  rope  being  under  his  bed,  accounting  to  himself  satisfac- 
torily as  to  its  presence,  as  this  patient  might  have  done  if 
she  had  not  been  insane,  would  have  removed  it  or  have 
had  it  removed,  and  neither  thought  nor  said  anything 
momentous  about  it  afterwards.  A  paretic  dement  came 
to  the  writer's  clinic,  whose  occupation  was  that  of  an 
artist's  and  anatomist's  model.  He  asserted  that  he  was 
the  best  built  man  in  the  United  States.  Having  to  un- 
dress him  before  the  class,  as  he  offered  his  services  in  his 
professional  capacity,  the  fact  was  revealed  that  he  had  a 
magnificent  figure  and  a  wonderful  muscular  development. 
But  his  announcement  was,  notwithstanding,  that  of  a 
paretic  dement,  for  further  inquiry  revealed  the  fact  that 
the  "girls  looked  at  him  because  he  had  a  peculiar  expres- 
sion in  his  eyes  which  they  fancied."  The  sanity  or  in- 
sanity of  an  idea  can  be  gleaned  from  its  inherent  con- 
struction, and  psychiatry  would  be  no  science  if  the  physi- 
cian were  compelled  to  rely  on  his  ability  as  a  detective  of 
family  secrets  to  exclude  fraud  and  to  make  a  diagnosis. 

It  may  be  laid  down  as  a  general  rule  that,  in  examining 
a  suspected  insane  patient,  the  physician  should  proceed 
as  if  he  wei^e  examining  the  mental  calibre  of  a  sane  per- 
son, except  where  the  injunctions  laid  down  above  require 
a  deviation  from  this  rule.  Though  disordered,  the  insane 
mental  mechanism  is  not  always  grossly  different  from 
the  mechanism  of  the  sane  mind;  and  it  is  particularly  the 
tyro  who  should  hold  prominently  in  view  the  fact  that,  in 
venturing  to  examine  an  alleged  lunatic,  he  may  encounter 
as  much  and  sometimes  more  wit,  cunning,  and  knowledge 
of  mankind  in  such  a  lunatic  than  he  is  himself  possessed 
of.  And  while,  as  a  rule,  the  mind  of  the  insane  is  diffuse- 
ly pervaded  and  weakened  by  morbid  ideas  or  by  impend- 
ing deterioration,  yet  here  and  there  the  physician  may 
have  the  tables  completely  turned  on  him  by  a  ready  pa- 
tient, if  he  ventures  outside  of  his  province  as  a  physician. 

In  his  demeanor  toward  all  patients  the  examiner  should  be 
gentle,  yet  firm.  He  will  find  the  skill  oi  a  cross-examining 
lawyer  or  of  a  detective  very  useful,  particularly  in  his  in- 
quiries of  members  of  the  family  in  whose  statements  the 
truth  is  sometimes  difficult  to  winnow  from  the  fancies  of 
the  laity  ;  but  his  behavior  should  never  approach  that  of 
the  members  of  either  of  these  professions.  There  is  a 
popular  delusion  that  the  human  eye  has  an  influence 
over   the    insane    similar   to    that    claimed    for    the    same 


330  INSANITY. 

organ  over  wild  animals;  a  delusion  that  the  writer  has 
known  the  insane  themselves  to  ridicule,  and  which  he 
who  attempts  to  utilize  will  learn  to  recognize  the  ab- 
surdity of  at  the  first  attempt.  An  overbearing,  haughty 
demeanor,  a  patronizing,  condescending  air  and  fidgetiness, 
are  all  equally  to  be  deprecated,  because  they  will  all 
equally  tend  to  defeat  the  purposes  of  an  inquiry.  He  who 
has  the  characteristics  necessary  to  constitute  a  member  of 
a  learned  profession  will  require  no  stage  effects  to  aid  in 
the  accomplishment  of  a  serious  inquiry;  he  needs  but  to 
act  perfectly  naturally,  that  is,  with  earnestness  and  scien- 
tific purpose. 


CHAPTER  II. 


The  Differential  Diagnosis  of  the  Various  Forms  of 

Insanity. 

As  briefly  hinted  in  the  last  chapter,  the  physician  diag- 
nosticating insanity  is  frequently  in  a  different  position 
from  him  who  is  called  upon  to  investigate  the  existence  of 
a  bodily  disease.  He  is  met  by  obstacles  of  a  kind  rarely 
presenting  themselves  in  general  practice,  and  he  must 
adopt  the  first  symptom  noticed  as  a  cue,  and  be  guided  in 
the  further  analysis  by  incidental  circumstances  varying 
with  each  case.  Such  a  clean-cut  routine  as  that  adopted 
in  physical  diagnosis,  with  its  neat  exclusions  and  com- 
binations, is  not  always  at  the  disposal  of  the  alienist, 
though  the  methods  of  psychological  diagnosis  are  analo- 
gous to  those  of  general  medicine.  In  the  sequel  it  will 
be  attempted  only  to  indicate  the  salient  points  of  diagno- 
sis, and  not  to  cover  rare  and  exceptional  cases. 

Let  us  suppose  that  the  physician  is  introduced  to  a  patient 
who  is  quiet,  passive,  and  whose  attitude  is  relaxed.  He 
will  remember  that  this  condition  may  be  found  in  the  fol- 
lowing forms  of  insanity  : 

1.  Simple  melancholia. 

2.  The  melancholic  and  cataleptic  phases  of  katatonia. 

3.  Stuporous  insanity. 

4.  Primary  deterioration. 

5.  Apathetic  dementia. 


DIFFERENTIAL   DIAGNOSIS.  33I 

6.  Senile  dementia. 

7.  Insanity  of  pubescence. 

8.  Prodromal  and  depressive  phases  of  paretic  dementia. 

9.  Prodomal  period  of  mania. 

10.  Dementia  from  coarse  brain  disease. 

11.  Alcoholic  insanity  and  other  toxic  forms. 

12.  Periodical  melancholia. 

13.  Melancholic  phase  of  circular  insanity. 

14.  Monomania  with  ideas  of  persecution. 

15.  Imbecility. 

16.  Post-epileptic  stupor. 

Perhaps  some  salient  symptom  may  be  manifested  by  the  pa- 
tient which  alone  suffices  to  establish  the  narrower  diagnosis 
between  these  forms,  but  let  us  suppose  that  the  physician  is 
compelled  to  resort  to  the  process  of  exclusion.  He  will 
bear  in  mind  that  absolute  fnutism  is  characteristic  only  of  : 

1.  The  atonic  variety  of  simple  melancholia. 

2.  Tlie  cataleptic  phases  of  katatonia. 

3.  Stuporous  insanity. 

4.  Atonic  melancholic  phases  of  circular  insanity. 

5.  Periodical  melancholia  of  the  atonic  kind. 

6.  Monomania,  and  other  forms  of  insanity  with  over- 
powering delusions. 

If  the  patient's  expression  betrays  intelligence  and  men- 
tal activity,  or  is  ecstatic,  he  is  likely  to  be  a  monomaniac 
acting  under  delusional  commands;  if  he  resists  manipula- 
tion the  same  is  true,  or  he  may  be  suffering  from  the 
toxic  forms,  or  be  in  a  visionary  trance.  His  earlier  his- 
tory will  reveal  the  absence  of  a  deeper  emotional  condi- 
tion, and  either  the  statements  of  the  friends  or  the  patient's 
documents  will  betray  the  existence  of  systematized  or  vi- 
sional delusions.  If  this  form  can  be  excluded,  which  is 
usually  easy,  the  diagnosis  lies  between  the  atonic  varieties 
of  simple  and  of  periodical  melancholia,  or  of  cyclical  in- 
sanity on  the  one  hand,  and  stuporous  insanity  and  kata- 
tonia on  the  other.  In  the  three  former  spasmodic  contrac- 
tion (tetany)  of  the  facial  muscles  is  sometimes  found,  in 
the  two  latter  never;  and  when  this  spasmodic  contraction 
of  the  facial  muscles  is  absent  in  true  melancholic  condi- 
tions, there  is  either  an  anxious  or  terrified  expression  in 
the  patient's  face.  Per  contra,  an  absence  of  expression  is 
characteristic  of  stuporous  insanity  and  the  cataleptic  pe- 
riods of  katatonia.  The  latter  is  readily  recognizable  by 
the   characteristic  symptom  of  waxy  flexibility;  while   the 


332  INSANITY. 

patient  whose  countenance  is  equally  blank,  who  is  similarly 
mute  and  inactive,  but  who  does  not  exhibit  waxy  flexi- 
bility, is  most  probably  a  stuporous  lunatic. 

The  absolute  diagnosis  in  all  these  cases  can  only  be 
made  with  the  aid  of  the  previous  or  the  subsequent  history 
of  the  case.  Thus,  if  the  patient  has  had  attacks  of  a  similar 
kind  before  and  at  approximately  regular  intervals,  and 
they  have  been  of  the  true  melancholic  character,  and  of 
this  character  onl}^  the  case  is  one  of  periodical  melancholia. 
If  there  have  been  such  attacks  previously,  but  in  alterna- 
tion with  maniacal  paroxysms,  it  is  one  of  circular  insanity 
in  its  melancholic  phase.  It  is  to  be  recollected  that  both 
periodical  melancholia  and  cyclical  insanity  are  rare  affec- 
tions, while  simple  melancholia  is  a  very  common  form  of 
insanity;  and  that  both  the  former  are  apt  to  develop  with 
great  rapidity,  while  it  is  exceedingly  rare  for  them  to 
reach  the  degree  of  atony.  The  etiological  history  is  also 
a  collateral  aid  in  determining  the  probabilities  of  the  case. 
Thus,  a  melancholia  which  can  be  referred  to  mal-nutrition, 
to  the  puerperal  state,  to  pregnancy,  to  excessive  lactation, 
or  to  mental  depressing  causes,  is  more  likely  to  be  a  simple 
melancholia  than  a  periodical  or  cyclical  form;  these  are 
developed  independently  of  the  exciting  causes  of  simple 
insanity. 

Other  points,  which  aid  in  the  differentiation  of  these 
forms  are  the  following  :  When  the  patient  suffering  from 
stuporous  insanity  shows  any  signs  of  mental  life  (p.  159) 
these  are  not  in  the  direction  of  raptus-like  explosions  or 
deliria  of  fear,  like  the  remissions  of  atonic  melancholia 
(p.  145).  The  katatonic  patient,  while  he  presents  an  emo- 
tional disturbance  which  is  altogether  absent  in  the  stupor- 
ous lunatic,  differs  from  the  melancholiac  in  that  he  rarely 
exhibits  deep  emotional  depression,  but  ideas  of  importance 
or  a  morbidly  pathetic  state  or  verbigeration  intermingled 
with  his  depressive  motions  (p.  151).  There  are,  however, 
cases  of  katatonia  which,  while  in  the  melancholic  phases, 
cannot  be  distinguished  from  true  melancholia. 

We  have  seen  that  if  the  patient  does  not  speak  at  all, 
that  the  diagnosis — difficult  as  it  seems  on  first  sight — can 
be  made  with  approximate  accuracy  even  under  this  dis- 
couraging circumstance.  Let  us  now  return  to  the  fifteen 
forms  (for  stuporous  insanity  may  be  excluded)  of  which 
motor  inactivity   and   apparent   depression    are    the   first 


DIFFERENTIAL   DIAGNOSIS.  333 

indications  noted  on  examination,  and  with  which  it  is 
supposable  that  mutism  does  not  exist. 

If  there  are  fixed  systematized  delusions  of  persecution 
(p.  26),  the  examiner  may  assume  that  the  case  can  be  only 
one  of  monomania.  If  there  are  unsystematized  delusions 
of  a  hypochondriacal  kind,  the  diagnosis  will  lie  between 
the  prodromal  period  of  paretic  dementia  and  melancholia. 
The  existence  of  motor  disturbances  (p.  207),  and  the 
specific  character  of  the  delusions  (p.  195),  characterize  the 
former  affection;  a  subjective  feeling  of  worthlessness  and 
deep  seriousness  of  manner  are  more  likely  to  be  found 
with  the  latter  disorder.  The  hypochondriacal  paretic  is 
more  communicative  and  more  likely  to  make  petulant 
complaints  than  the  true  melancholiac,  who  is  more  retir- 
ing, secretive,  and  suspicious. 

Among  the  forms  enumerated  at  the  head  of  this 
chapter  as  possibly  associated  with  seeming  depression  a 
distinction  can  be  made  on  the  strength  of  the  mental  rank 
of  the  patient.  This  is  decidedly  low  in  apathetic  and  se- 
nile dementia,  in  insanity  of  pubescence,  in  dementia  from 
coarse  brain  disease,  and  in  imbecility.  Of  these  forms  in- 
sanity of  pubescence  is  characterized  by  the  shallow  silli- 
ness and  sham  character  of  the  emotions  of  its  subjects  as 
well  as  by  its  occurrence  at  and  shortly  after  the  period  of 
puberty.  Senile  dementia  is  similarly  characterized  by  its 
association  with  the  senile  state,  the  amnesia  of  the  patients 
for  recent  events,  their  suspicions,  and  miserliness  (p.  172). 
Dementia  from  coarse  brain  disease  is  recognizable  by  its 
association  with  the  physical  signs  of  ordinary  brain  lesions. 
Apathetic  dementia  has  characters  which  are  negative,  but 
the  history  of  a  preceding  psychosis  will  demonstrate  that 
the  present  disorder  is  only  the  terminal  phase  of  another 
and  long-past  form  of  insanity;  while  imbecility  is  ordinar- 
ily marked  by  somatic  signs  of  imperfect  development,  or 
by  the  history  of  early  and  primary  mental  defect.  In  the 
dement  there  are  almost  always  flashes  breaking  through 
the  cloud  of  mental  darkness,  proving  that  there  has  at  one 
time  been  more  mental  power  than  the  patient  now  has;  in 
the  imbecile  the  mind,  as  far  as  it  goes,  indicates  a  perma- 
nent organization. 

Delusions  of  persecution  of  the  unsystematized  kind 
characterize  the  different  forms  of  melancholia,  the  melan- 
cholic phases  of  katatonia,  the  depressive  phases  of  paretic 


334  INSANITY. 

dementia,  alcoholic  and  other  toxic  insanities,  and  the  post- 
epileptic forms. 

Melancholia,  whether  simple,  periodical,  or  in  cyclical  de- 
velopment, differs  from  the  other  forms  here  mentioned  by 
the  depth  of  the  emotions.  In  periodical  and  cyclical  forms 
the  delirium  growing  out  of  the  delusions  is  apt  to  be  sub- 
dued and  to  have  a  more  "  reasoning  character"  (approx- 
imating in  this  respect  the  systematized  delusion)  than 
that  of  simple  melancholia.  The  patients  are  also  apt  to 
show  a  moral  perverseness  and  irritability,  rare  at  best  in 
simple  melancholia.  In  addition,  the  history  of  previous 
attacks  and  of  their  character,  herein  already  referred  to, 
will  serve  to  establish  the  nature  of  the  melancholia. 

Post-epileptic  stupor  and  post-epileptic  insanity  with  de- 
pression are  recognizable  by  the  peculiar  drunken  appear- 
ance of  the  patients,  their  combined  religious  and  sexual 
delusions,  the  previous  occurrence  of  fits,  the  sudden  de- 
velopment of  the  symptoms,  the  prevalence  of  angry  ex- 
citement i/nassociated  with  expansive  flights  of  ideas,  and  the 
deep  disturbance  of  consciousness.  The  alcoholic  forms 
are  characterized  by  their  association  with  ghastly  halluci- 
nations, the  delusions  of  marital  infidelity,  sexual  mutila- 
tion, and  poisoning,  and  the  physical  signs  of  alcoholism. 

It  is  impossible  in  the  present  imperfect  state  of  our 
knowledge  to  indicate  the  signs  by  which  the  chronic  form 
of  opium  insanity  can  be  recognized.  As  far  as  the  writer's 
experience  goes  absolute  mutism  may  here  occur  under 
delusional  influences,  exactly  as  in  monomania;  while,  on 
the  other  hand,  visions  of  a  religious  character  are  likely, 
and  hallucinations  of  a  kind  resembling  those  of  acute 
mania  and  confusional  insanity  are  common. 

If  none  of  the  positive  signs  which  are  pathognomonic  of 
the  special  forms  are  discoverable  in  the  way  of  disturb- 
ances of  the  memory,  of  consciousness,  hallucinations,  and 
delusions,  the  diagnosis  rests  between: 

1.  Melancholia  sine  delirio. 

2.  The  prodromal  period  of  mania. 

3.  The  prodromal  period  of  some  cases  of  paretic  de- 
mentia. 

4.  Primary  deterioration. 

Melancholia  sine  delirio  is  recognizable  by  the  continu- 
ously gloomy  disposition  of  the  patient  unassociated  with 
formal  disturbance  of  the  intelligence.  The  depression  is 
entirely  subjective.     In  primary  deterioration  and  the  pro- 


DIFFERENTIAL   DIAGNOSIS.  335 

dromal  period  of  depression  of  simple  mania,  on  the  other 
hand,  the  depression  is  the  result  of  the  recognition  by  the 
patient  that  his  mental  powers  are  more  sluggish  than  of 
yore,  and  that  he  is  unable  to  exert  his  will-power  or  carry 
on  his  duties.  Between  these  two  conditions  the  diagnosis 
can  in  turn  be  made  by  the  fact  that  in  primary  deteriora- 
tion there  are  usually  serious  lacunae  in  the  memory,  which 
are  absent  in  mania.  If  this  differentiation  is  impossible, 
the  subsequent  course  of  the  trouble  will  soon  establish  the 
diagnosis  beyond  doubt.  Primary  deterioration  if  properly 
treated  may  be  permanently  arrested,  or,  if  we  are  unable 
to  check  it,  will  progress  in  the  same  direction  ;  the  pro- 
dromal period  of  typical  mania,  however,  is  followed  by  the 
maniacal  explosion. 

In  the  vast  majority  of  cases  the  prodromal  depressive 
stage  of  paretic  dementia  can  be  recognized  by  means  of 
the  criteria  given  on  page  187.  The  patients  exhibit  an 
undue  irritability  in  small  matters,  and  apathy  as  well  as 
abulia  with  regard  to  important  ones,  a  contrast  not  found 
in  primary  deterioration.  The  peculiar  abstraction  of  the 
paretic  is  a  characteristic  symptom  of  paretic  dementia  not 
found  either  in  melancholia  sine  delirio  nor  in  the  pro- 
dromal period  of  mania  ;  while  the  oddities  of  behavior 
observed  in  the  former  condition  are  never  found  in  the 
latter  two  disorders. 

Let  us  now  suppose  that  the  patient  exhibits  motor  excite- 
ment.    This  is  found  in  : 

1.  Simple  mania. 

2.  The  maniacal  phases  of  paretic  dementia. 

3.  Transitory  frenzy. 

4.  Agitated  dementia. 

5.  Agitated  melancholia. 

6.  Periodical  mania. 

7.  Maniacal  phase  of  cyclical  insanity. 

8.  Epileptic  insanity. 

9.  Episodical  frenzy  of  chronic  insanity. 

The  differentiation  here  can  be  made  according  to  the  char- 
acter of  the  associated  mental  state.  Agitated  melancholia 
is  readily  recognizable  by  the  complaints  and  the  panphobia 
of  the  patient;  agitated  terminal,  as  well  as  agitated  senile, 
dementia,  by  the  motiveless  character  of  the  patient's 
activity.  In  epileptic  insanity  with  motor  excitement,  in 
transitory  frenzy,  and  in  the  frenzy  of  mania  and  paretic 
dementia,  there  is  disturbance  of  consciousness,  and  for 
this  reason  the  closer  diagnosis  between  them  cannot  always 


336  INSANITY. 

be  made  on  the  spur  of  the  moment.  The  history  of  epi- 
leptic fits,  the  association  of  religious  and  sexual  ideas,  the 
dreamy  character  of  the  excitement,  and  the  frequently 
present  motor  weakness,  serve  to  distinguish  epileptic 
frenzy.  Angry  excitement  combined  with  expansive  and 
aggressive  delirium  is  equally  found  in  maniacal  and 
paretic  frenzy,  their  resemblance  being  increased  by  the 
temporary  erasure  of  the  motor  signs  in  the  latter  state. 
This  is,  however,  never  complete  in  the  later  periods  of 
paretic  dementia.  The  diagnosis  of  transitory  frenzy  is 
usually  made  after  the  attack  is  over,  and  when  the  existence 
of  epilepsy  or  of  other  neurotic  conditions  has  been  excluded. 

The  same  rules  which  were  given  above  for  the  dis- 
tinguishing of  simple  melancholia  from  the  periodical  and 
cyclical  forms,  apply  to  the  differentiation  of  simple  mania 
from  periodical  mania  and  the  maniacal  phases  of  cyclical 
insanity. 

From  the  fact  that  paretic  dementia  imitates  various 
phases  of  other  psychoses,  it  is  of  the  very  highest  import- 
ance to  properly  appreciate  the  exact  value  of  the  signs 
whose  presence  or  absence  justifies  us  in  making  a  positive 
diagnosis  of  this  affection,  or  to  exclude  it.  To  do  so  it  is 
necessary  to  refer  to  many  errors  current  on  this  head.  It 
is  generally  believed  that  the  unsystematized  delusion  of 
grandeur — as, for  example, the  belief  of  great  personal  beauty^ 
of  Herculean  strength,  and  of  vast  possessions — is  pathog- 
nomonic of  this  disorder.  But  the  same  delusions  may  be 
found  in  simple  mania  as  well — though,  it  is  true,  rarely  in 
the  same  extravagant  form.  With  many  it  suffices  to  detect 
a  pupillary  difference  and  a  tremor  of  the  outspread  fingers, 
in  addition  to  such  delusions,  to  render  the  diagnosis  of 
paretic  dementia  a  certainty  in  their  minds.  It  must  be 
recollected  in  this  connection  that  not  only  are  differences 
in  the  pupillary  diameters  found  in  simple  mania,  in  melan- 
cholia, and  in  monomania,  but  also  in  perfectly  sane  per- 
sons, either  congenitally  or  in  the  consequence  of  unilateral 
ej'^e-strain,  as  in  microscopists  and  watchmakers,  or  as  the 
result  of  the  obscure  influence  of  visceral  disease  ;  thus  the 
right  pupil  is  sometimes  found  dilated  in  hepatic  disease, 
the  left  in  cardiac,  splenic,  and  gastric  affections,  and  a 
similar  sympathy  has  been  found  to  exist  between  unilateral 
pulmonary  disease  and  the  state  of  the  pupil  on  the  same 
side.* 

*  The  possible  existence  of  an  aneurism  should  not  be  forgotten  in  this 

connection. 


DIFFERENTIAL   DIAGNOSIS.  337 

As  to  tremor  of  the  outspread  fingers,  it  is  a  common 
sign  in  many  other  forms  of  insanity,  and  is  characteristic 
of  numerous  nervous  disorders  which  have  nothing  to  do 
with  paretic  dementia.  In  persons  suffering  from  nervous 
exhaustion  or  alcoholism  it  is  common  ;  in  monomania  an 
emotional  tremor  is  almost  always  found  with  episodical 
excitement,  and  the  same  is  true  of  insanity  with  excite- 
ment generally.  In  all  these  cases  if  the  patient's  attention 
is  directed  to  the  desirability  of  keeping  the  hand  steady, 
the  tremor  diminishes  up  to  a  certain  point,  while  the  hand 
is  held  out.  In  paretic  dementia  the  tremor  increases  the 
longer  the  hand  is  held  out,  and  is  more  excursive  and 
irregular,  though  the  rhythm  is  sometimes  finer  than  that 
observed  in  the  conditions  mentioned. 

The  writer  has  also  met  with  a  case  where  the  diagnosis 
of  paretic  dementia  had  been  erroneously  made  in  a  patient 
suffering  from  posterior  spinal  sclerosis,  and  who  had  had 
in  addition  an  attack  of  suicidal  melancholia.  Spinal-cord 
affections  may  be  accompanied  or  complicated  by  insanity, 
which  may  or  may  not  have  an  essential  connection  with 
them.  It  is  particularly  in  the  course  of  locomotor  ataxia 
(posterior  spinal  sclerosis)  that  delirious  frenzy  or  melan- 
cholia acutissima  may  occur  and  disappear  with  equal  sud- 
denness.* 

When  paretic  dementia  is  so  far  advanced  that  its  episodes 
may  be  confounded  with  those  of  mania,  symptoms  will  be 
observable,  after  the  maniacal  attack  has  subsided,  which 
leave  no  room  for  a  doubt  as  to  the  diagnosis.  The  sudden- 
ness with  which  the  patient  emerges  from  the  attack,  his 
residual  delusions,  irritability,  and  amnesia,  involving  events 
preceding  the  maniacal  outbreak,  are  in  striking  contrast 
with  the  usually  gradual  disappearance  of  true  mania,  the 
lucidity  of  its  convalescent  periods,  and  the  complete  recovery 
of  the  recollections  accumulated  prior  to  the  illness,  and  often 
even  of  those  accumulated  in  its  course.  But,  in  addition, 
there  are  observed  in  the  paretic  dement  under  these  cir- 
cumstances speech  disturbances,  paresis  of  certain  muscular 
groups,  and  a  fibrillary  tremor  of  the  tongue  which  are 
found  in  no  other  form  of  insanity  in  a  similar  grouping 
(p.   191),  except  in  the  allied  one  of  syphilitic  dementia. 

In  the  earlier  periods  of  paretic  dementia,  when  the  men- 

*  Probably  due  to  an  anatomically  impalpable  involvement  of  the  in- 
tracranial vasomotor  centre. 


338  INSANITY. 

tal  sj^mptoms  are  either  those  of  depression  and  hypo- 
chondriasis, which  in  their  differential  relations  have  been 
discussed  above,  or  of  a  subdued  maniacal  kind,  the  diag- 
nosis may  be  more  difficult,  for  the  physical  signs  are  then 
not  always  well  marked,  though  the  characteristic  facies 
of  this  disease  (p.  209)  is  sometimes  already  present  at  this 
time.  In  its  absence  the  following  signs,  or  the  combina- 
tion of  several  of  them,  point  to  the  existence  of  paretic 
dementia  with  almost  unerring  certainty:  ist.  Morning 
headache  of  a  dull  kind,  either  described  as  comparable  to 
an  encircling  band  or  to  a  grinding  sensation,  which  may 
be  so  severe  in  some  cases  as  to  cause  the  patient  to  cry 
out  and  to  beat  his  head  against  the  wall;  2d.  The  siiddefi 
disappearance  of  this  headache,  accompanied  by  a  subjective 
feeling  of  lightness  and  exaltation;  3d.  Sudden  stoppage 
of  words,  or  momentary  cessation  of  ideation;  4th.  Ab- 
straction in  the  midst  of  conversation,  with  corresponding 
mental  lacunae;  5th.  Congestive  attacks,  associated  with 
the  word-stoppages  and  fits  of  abstraction;  6th.  Drowsi- 
ness after  meals;  7th.  Dreams  of  a  vivid  and  usually  disa- 
greeable character;  8th.  Amnesia  for  special  events  or 
series  of  events;  9th.  Vertigo  independent  of  gastric  dis- 
turbance. All  these  signs,  with  the  exception  of  the  sec- 
ond, may  be  premonitory  of  focal  organic  disease  of  the 
brain,  and  it  would  be  impossible  to  characterize  the  symp- 
toms of  paretic  dementia  in  the  early  stage  better  than  by 
saying  that,  in  addition  to  the  prodromal  signs  of  the 
ordinary  psychoses,  there  must  be  the  prodromal  signs  of 
ordinary  brain  disease  to  justify  a  positive  diagnosis. 
Neither  group  by  itself  is  sufficient  to  prove,  though  it 
may  be  strongly  suggestive  of  the  existence  of,  this  disease. 
The  occurrence  of  an  epileptiform  fit,  or  of  an  apoplecti- 
form attack,  particularly  if  there  be  a  rapid  recovery  from 
their  grosser  effects,  gives  strong  support  to  the  diagnosis,* 
if  either  is  present. 

It  may  be  assumed  to  be  a  general  rule  that  even  in  the 
early  stage  of  paretic  dementia  there  is  more  mnemonic 
and  logical  enfeeblement  than  in  mania  or  melancholia  in 
the  corresponding  period. 

The  countenance  in  paretic  dementia  is  supposed   to   be 

*  The  occurrence  of  an  epileptiform  attack  after  a  maniacal  paroxysm, 
is  not  in  itself  proof  of  the  existence  of  paretic  dementia.  Worthing- 
ton)  yotirital  of  Mental  Science,  October,  i88i)  reports  a  case  of  mania  in 
puei-pero,  ending  in,  and  apparently  "cured"  by,  an  epileptic  fit. 


DIFFERENTIAL   DIAGNOSIS.  339 

one  of  its  most  characteristic  features,  and  in  the  over- 
whelming majority  of  cases  in  which  such  a  countenance  is 
found  that  disease  is  present.  But  there  are  three  condi- 
tions in  which  a  similar  appearance  may  be  discovered: 
the  saturnine  cerebral  disorder,  monomania  with  deteriora- 
tion, and  bromine  saturation.  In  the  saturnine  encephal- 
opathy the  expression  of  the  paretic,  his  facial  pareses,  and 
the  labial  tremor  are  closely  imitated.  In  monomania 
with  delusions  of  persecution  of  long  duration  there  is  the 
same  corrugation  of  the  brow  (Fig.  13),  not  the  effect  of  a 
compensatory  effort,  as  in  paretic  dementia,  but  the,  as  it 
were,  petrified  expression  of  care  and  dread.  The  congenital 
facial  asymmetry  and  defective  innervation  of  one  side  of 
the  face  sometimes  found  in  monomania  increase  the  re- 
semblance. The  following  points  will  serve  to  distinguish 
the  two:  When  there  is  marked  corrugation  of  the  brow 
in  paretic  dementia  there  is  always  in  addition  more  or 
less  ptosis  in  the  writer's  experience;  this  is  usually  absent  in 
monomania,  though  in  subjects  of  a  neuropathic  constitution 
a  slight  degree  of  ptosis  is  sometimes  found.  In  case  this 
leads  to  a  doubt  in  diagnosis  the  examination  of  a  photo- 
graph taken  some  years  before  will  reveal  its  true  nature.  If 
present  then,  it  can  not  now  be  an  indication  in  itself  of  paretic 
dementia.  When  there  is  asymmetry  or  unequal  innerva- 
tion in  monomania  there  is  never  the  exaggerated  (snarl- 
like) action  of  the  muscles  of  the  nasolabial  fold  so  fre- 
quently noticeable  in  the  paretic  dement  when  excited  or 
after  speaking  any  length  of  time.  A  fine  emotional  tremor 
may  be  present  in  monomania,  but  the  spasmodic  twitches 
of  isolated  facial  muscles  or  their  fasciculi,  so  multitudi- 
nous in  paretic  dementia,  do  not  occur  much  more  frequently 
in  monomania  than  in  that  portion  of  the  sane  population 
which  suffers  from  insomnia  and  other  accompaniments  of 
nervous  exhaustion  and  over-strain.  There  are  sometimes 
observed  excursive  spasmodic  contractions  in  monomania, 
but  they  resemble  in  character  the  tic  convulsif  and  are  not 
fibrillary.  They  usually  involve  one  entire  side  of  the  face,  a 
distribution  which,  if  it  ever  occurs  in  paretic  dementia,  is  ex- 
ceptional. In  patients  suffering  from  brominism  a  combined 
condition  of  mental  impairment  and  defective  facial  inner- 
vation is  found,  which,  on  first  sight,  strongly  suggests  the 
existence  of  paretic  dementia.  The  writer  has  seen  double 
ptosis,  a  stony  stare,  lax  facial  folds,  zygmotic,  labial,  and 
lingual  tremor,  in  one  male  (a  physician)  and  in  one  female 


340  INSANITY. 

patient,  which  exactly  imitated  the  appearance  of  advanced 
paretic  dementia  as  noted  after  epileptiform  attacks.  The 
apparent  stupor  of  the  brominized  patient,  his  ataxia  and 
paraparesis,  cannot,  however,  be  confounded  with  the  super- 
Jicially  similar  symptoms  of  paretic  dementia.  The  pa- 
tients have  full  ego  consciousness,  though  their  reception, 
registration,  and  reproduction  of  impressions  is  temporarily 
impaired;  but  while  it  is  altogether  impossible  to  remind 
the  paretic  dement  of  certain  events  which  happened  some 
time  before,  the  brominized  subject  can  usually  be  brought 
to  recollect  them  on  suggestion.  The  patient  struggles 
against  his  amnesia,  just  as  he  makes  frequent  efforts,  like 
a  drunken  person,  to  straighten  out  his  features  and  raise 
his  lids.  His  stagger  is  very  much  like  the  stagger  of  a  per- 
son intoxicated  with  alcohol,  a  character  which  the  paretic's 
stagger  does  not  imitate  as  closely,  because,  while  the  par- 
etic's stagger  has  the  combined  ataxic  and  paretic  character 
of  the  alcoholic  stagger,  there  is  not  that  same  struggle  to 
retain  the  equilibrium  which  is  common  to  the  drunken  and 
the  brominized  subjects. 

There  is  one  feature  observed,  not  in  all  but  in  a  large 
proportion  of  paretics,  toward  the  terminal  period  of  their 
illness,  which  is  never  found  in  any  other  condition,  except 
in  delirium  grave.  This  is  an  appearance  of  obliteration  of 
the  features  and  puffiness,  which  can  be  characterized  by 
no  single  term  so  well  as  by  "  sogginess. " 

Of  single  symptoms  which  merit  special  consideration  in 
their  differential  diagnostic  relations,  the  delusions  of  the 
insane  have  been  already  detailed  in  the  first  part  of  this 
volume  (p.  23).  The  discrimination  there  made  of  systema- 
tized delusions  and  unsystematized  delusions  may  be  sup- 
plemented by  the  following: 

I.  Systematized,  fixed  delusions  are  found  only  in  mono- 
mania and  hysterical  insanity. 

II.  A  feeble  systematization  of  delusions,  that  is,  an  ap- 
proach to  a  compliance  with  the  demands  of  logic  and  con- 
sistency, is  sometimes  observed  in  periodical  insanity. 

III.  The  delusions  of  alcoholic  insanity  are  fixed  as  to 
their  general  contents,  but  they  are  not  logically  systema- 
tized. 

IV.  The  delusions  of  mania  are  constructive,  and  fre- 
quently display  some  logical  and  creative  power,  but  they 
are  never  stable  enough  to  become  systematized. 

V.  Fixed,  that  is  permanent,   delusions  are   observed  in 


DIFFERENTIAL   DIAGNOSIS.  34I 

secondary  confusional  insanity  without  logical  correlation, 
and  therefore  are  unsystematized  (p.  170). 

VI.  The  delusions  of  some  imbeciles,  without  showing 
logical  strength,  creative  power,  and  systematization,  bear 
the  same  relation  to  the  mental  mechanism  of  the  imbecile 
that  the  systematized  delusions  of  the  monomaniac  do  to  his. 
They  are  as  permanent,  and  control  the  <?§-t7  proportionately. 

The  rapidity  with  which  delusions  develop  is  also  of 
some  significance.  The  systematized  delusions  of  mono- 
mania are  the  result  of  a  process  of  reflection,  and  are  con- 
sequently of  slower  growth  than  the  unsystematized  delu- 
sions of  some  other  forms  of  insanity;  and  an  apparently 
rapid  growth  of  them  is  always  associated  with  preceding 
visions,  which  are  in  turn  the  subjective  confirmations  of 
previous  morbid  trains  of  thought.  Sometimes  the  most 
extravagant  delusions  of  paretic  dementia  develop  imme- 
diately after  a  sleepless  night,  or  after  a  series  of  epilep- 
tiform attacks. 

The  delirium,  that  is,  the  flight  of  ideas  of  the  insane,  pre- 
sents characteristic  features  in  various  forms  of  insanity. 
The  older  German  writers  distinguished  true  maniacal 
delirium  from  so-called  moria.  Under  this  latter  term  they 
comprised  those  deliria  which  are  marked  by  unreasona- 
bleness, or  are  of  a  shallow  and  foolish  character.  Such 
deliria  are  found  in  primary  and  secondary  confusional  in- 
sanity, in  the  epileptic  psychoses,  in  katatonia,  and  in  in- 
sanity of  pubescence.  The  higher  deliria  of  mania  and  of 
paretic  dementia  in  its  earlier  stages  are  characterized  by 
an  exalted  or  angry  emotional  state,  those  of  melancholia 
by  the  reverse,  and  those  of  delusional  monomania  by  their 
consistency  with  the  systematized  and  fixed  morbid  beliefs. 
In  hysterical  delirium  there  is  often  noticeable  an  exuber- 
ant fancy  with  an  approach  to  systematization. 

The  character  of  hallucinations  and  illusions  in  the  vari- 
ous forms  of  insanity  has  been  detailed  in  the  first  two 
parts  of  this  work.*  In  a  general  way  it  may  be  stated 
that  visions  of  an  elaborate  kind  are  rarely  found  in  any 
other  form  of  insanity  than  in  monomania.  More  confused 
visons  are  sometimes  observed  in  paretic  dementia  (p.  202). 
In  acute  insanit}'-  the  hallucinations  are  more  changeable, 
and  what  were  previously  characterized  as  "multitudinous" 

*  Pp.  49—54.  134.  142,  152,  163,  174,  200,  248,  254,  257.  303,  304, 
and  317. 


342  INSANITY. 

hallucinations  (p.  48)  are  indicative  of  alcoholic,  epileptic, 
or  opium  insanity,  and  occasionally  of  paretic  dementia. 

Let  us  now  apply  the  foregoing  to  a  few  cases,  which 
may  serve  as  illustrations  of  the  methods  of  diagnosis  to  be 
followed  in  mental  disease:  I.  The  physician  is  called  to  a 
female  patient  about  eighteen  years  old;  she  is  seated  on  a 
bed,  of  which  the  bedding  and  blankets  are  in  great  disor- 
der, and  vociferating  loudly.  These  few  facts  will  indicate 
to  him  that  he  has  to  deal  either  with  maniacal  excitement 
of  some  form,  melancholic  frenzy,  or  hysterical  simulation. 
On  approaching  closer,  the  patient  applies  some  remarks 
to  him,  either  calling  on  him  to  protect  her  against  assas- 
sins, or  accusing  him  of  being  in  league  with  them.  All 
this  might  occur  in  either  of  the  three  conditions  named, 
but  diminishes  the  probability  of  hysterical  simulation. 
Her  expression  is  animated,  and  she  continually  spits  out 
saliva  into  her  handkerchief,  asserting  that  tliis  is  the  poi- 
son administered  by  her  foes  which  is  driven  out  by 
some  counter-poison  given  her  by  her  friends.  There  is  a 
marked  effluvium  in  the  room,  due  to  the  exaggerated 
cutaneous  secretions,  and  the  history  is  given  that  the  pa- 
tient has  been  in  nearly  the  same  condition  for  over  a  week. 
The  physical  signs  noted,  the  history,  and  the  character  of 
the  ideas  positively  exclude  hysteria.  The  first  delusions 
expressed  by  the  patient  are  those  of  persecution,  and,  as 
far  as  this  is  concerned,  might  appertain  to  melancholia  as 
well  as  to  mania.  But  the  following  are  inconsistent  with 
melancholia:  i.  The  animated  look;  2.  The  recognition  of 
a  friendly  power  combating  her  foes;  3.  The  conscious- 
ness of  the  patient;  4.  Her  responsiveness.  On  listening 
to  the  word-delirium  it  is  found  to  be  multifarious,  relating 
to  a  great  many  objects;  she  can  be  checked  for  moments 
and  made  to  answer  reasonably  on  minor  topics;  finally,  on 
asking  her  why  she  is  pursued  and  why  her  parents  are 
"hired  ijiurderers,"  she  asserts  that  in  reality  she  is  the 
Princess  Louise,  and  that  they  are  not  her  parents.  Mel- 
ancholic frenzy,  and  indeed  melancholia  in  general,  may 
be  now  excluded,  for  they  are  inconsistent  with  ideas  of 
exaltation  and  creative  fancy;  but  the  new  suspicion  arises 
and  must  be  taken  into  account,  that,  after  all,  the  case 
may  be  not  one  of  pure  maniacal  excitement,  but  of 
monomania  with  episodical  delirium;  for  with  monomania, 
particularly  in  young  subjects  of  that  disorder,  the  de- 
lusion   of   being   exchanged    for   other   children,    and    de- 


DIFFERENTIAL   DIAGNOSIS.  34J 

prived  of  a  birthright  and  persecuted,  is  very  common, 
and  almost  characteristic  of  a  certain  group.  On  being 
questioned  further,  the  patient  herself  tells  the  physician 
that  she  has  not  entertained  this  idea  more  than  a  few 
days.  She  does  not  claim  to  be  princess  of  any  particular 
land,  and  while  she  asserts  that  her  parents  are  not  her  real 
parents,  she  is  not  able  to  say  who  the  latter  really  are; 
speaking  of  a  schoolmate  who  is  also  maltreated,  as  she 
claims,  by  her  parents,  she  expresses  the  suspicion  that  she 
too  may  be  in  reality  a  princess  brought  up  by  foster- 
parents.  The  lack  of  systematization,  and  the  suddenness 
with  which  the  delusion  arose,  disprove  the  suspicion  of 
monomania,  and  establish  the  diagnosis  of  maniacal  excite- 
ment. But  maniacal  excitement  may  be  found  in  a  num- 
ber of  psychoses.  The  sex  and  youth  of  the  patient,  as  well 
as  the  absence  of  motor  disturbances,  show  that  it  cannot 
be  a  maniacal  exacerbation  of  paretic  dementia.  The  pa- 
tient has  never  had  epilepsy,  which  fact  alone  would  show 
the  impossibility  of  its  being  an  epileptic  mania,  even  leav- 
ing out  of  consideration  the  comparative  clearness  and  con- 
sciousness of  the  patient,  the  absence  of  the  epileptic  ex- 
pression, and  of  sexual,  terrible  and  religious  delusions.  On 
making  inquiry  of  the  relatives  the  physician  finds  that  the 
patient  has  never  been  insane  before;  this  fact  renders  it  im- 
probable that  the  case  is  one  of  beginning  periodical  or 
cyclical  insanity.  In  addition  it  is  found  that  the  disorder 
exploded  with  hallucinations  and  illusions  of  the  identity  of 
others,  after  a  suppression  of  the  menses.  The  diagnosis 
can  then  positively  be  made  of  simple  mania. 

II.  The  physician  visitsa  patient  who  is  himself  desirous  of 
having  the  state  of  his  physical  and  mental  health  exam- 
ined, but  cannot  summon  up  resolution  enough  to  call  on 
the  doctor  himself.  It  is  only  in  melancholia,  in  incipient 
paretic  dementia,  or  mania  in  primary  mental  deterioria- 
tion,  and  in  hypochondriacal  monomania  that  the  patient 
is  likely  to  request  a  physician's  services  himself.  The  pa- 
tient rises  in  a  listless  way  to  greet  the  physician,  there  is 
an  expression  of  the  ermtn  of  invalidism  on  his  face,  and  his 
movements  are  slow  and  denote  a  certain  degree  of  ab- 
straction. His  tongue  is  coated,  the  appetite  poor,  and  the 
bowels  are  constipated.  He  gives  no  history  of  excessive 
mental  strain,  but  for  some  months  past  has  failed  to  at- 
tend to  his  business  properly,  neglected  it,  and  takes  no  in- 
terest in  it.     The  period  of  several   months  is  an  unusual 


344  INSANITY. 

one  for  the  prodromal  stage  of  simple  mania,  which  may  be 
provisionally  excluded  therefore.  The  patient,  on  being 
asked  why  he  is  unable  to  call  up  his  former  interest  in  his 
business,  says  that  he  is  disgusted  because  he  is  not  making 
enough  money  at  it.  At  the  same  time  he  does  not  show 
any  deep  emotion,  and  the  reminiscence  of  sad  occurrences 
does  not  affect  him.  This  renders  the  existence  of  simple 
melancholia  improbable.  On  re-directing  his  attention  to 
his  physical  state,  he  expresses  the  idea  that  his  bowels  are 
grown  together,  and  that  no  faeces  can  pass.  This  charac- 
teristic hypochondriacal  delusion  excludes  primary  deteri- 
oriation,  and  limits  the  diagnosis  to  hypochondriacal  mono- 
mania and  the  hypochondriacal  phase  of  paretic  dementia. 
His  wife  now  calls  attention  to  the  fact  that  he  has  had  a 
passage  from  his  bowels,  which  he  has  evidently  forgotten, 
and  he  is  apparently  nonplussed  by  the  reminder.  This 
speaks  strongly  against  hypochondriacal  monomania,  for 
here  the  fact  of  a  passage  would  be  accounted  for  by  some 
explanation  however  absurd,  as,  for  example,  that  there  was 
an  accumulation  below  the  stricture,  or  a  new  channel 
formed.  On  the  other  hand,  the  amnesia  displayed  with 
regard  to  an  occurrence  of  the  day  before,  which,  because 
related  to  the  patient's  morbid  ideation,  he  ought  to  recol- 
lect, if  a  systematic  delusionist,  much  better  than  even  a 
sane  person,  strongly  suggests  the  existence  of  paretic  de- 
mentia. In  addition  it  is  found  that  the  memory  has  be- 
come enfeebled,  that  the  patient  complains  of  a  sensation 
like  a  tight  band  around  his  head,  of  his  sleep  being  dis- 
turbed by  dreams  of  a  disagreeable  character;  his  color- 
field  is  found  limited,  while  there  is  pinhole  contraction  of 
the  pupils,  and  occasionally  a  fibrillary  twitch  in  the  facial 
muscles.  The  case  is,  therefore,  one  of  incipient  paretic 
dementia. 

An  important  fact  to  be  remembered  in  connection  with 
this  branch  of  the  subject  is  the  possibility  of  certain  forms 
of  chronic  insanity  being  complicated  by  the  more  acute 
forms.  Thus  typical  melancholia  and  mania  may  occur  in 
a  monomaniac  or  an  imbecile.  Here  the  diagnosis  will  not 
be  very  difficult.  It  is  different  with  regard  toacomplica- 
t'on,  which  the  writer  has  reason  to  consider  a  much  more 
fiv.quent  one  than  is  ordinarily  supposed,  namely,  that  of 
monomania  by  paretic  dementia.  The  writer  has  seen  two 
cases  of  this  combination  in  the  pauper  asylum  on  Ward's 
Island  and  two  in  private  practice.     In  one  of  the  latter, 


DIFFERENTIAL   DIAGNOSIS.  345 

morbid  projects  and  delusions  of  the  systematized  variety 
could  be  determined  to  have  been  entertained  by  the  pa- 
tient over  forty  years  before  the  outbreak  of  the  paretic 
disorder.  The  history  of  one  of  the  asylum  cases,  which 
was  completed  hy  3. post-mortem  record  showing  the  charac- 
teristic lesions  of  paretic  dementia,  is  so  instructive,  and 
in  more  than  one  respect  illustrates  the  differential  indica- 
tions referred  to  in  this  chapter,  that  it  is  appended  in  full. 
At  the  time  when  the  writer's  attention  was  most  closely 
directed  to  the  patient  he  presented  the  physical  signs  of 
progressive  paresis,  and  at  the  same  time  morbid  projects 
and  delusions.  While  some  of  these,  like  his  idea  that  the 
superintendent  was  responsible  for  the  introduction  of  ver- 
min into  the  institution,  and  that  he  was  going  to  build  an 
asylum  with  a  school  attached  to  it,  in  which  the  medical 
officers  were  to  be  properly  instructed  in  mental  science, 
notwithstanding  the  kernel  of  justification  for  the  latter 
intention,  were  unquestionably  true  paretic  notions,  others 
were  so  elaborate,  and  involved  such  an  excellent  memory 
and  fertility  of  invention,  that,  without  knowing  his  earlier 
history,  the  writer  suspected  that  the  paralytic  insanity 
was  engrafted  as  a  foreign  element  on  a  pre-existing  mono- 
mania. It  may  be  said  here  that  the  patient  had  a  fair 
recollection  of  some  of  the  experiments  of  Magendie,  a 
good  knowledge  of  anatomy,  was  a  fair  logician  and  ready 
writer,  even  to  the  time  when  he  could  hardly  enunciate 
words  properly,  and  was  unable  to  use  his  lower  extremi- 
ties. He  all  the  while  exhibited  the  characteristic  symp- 
toms of  querulous  monomania.  If  the  peculiar  character 
of  the  patient's  delusions  alone  justified  the  suspicion  en- 
tertained, that  the  paralytic  insanity  which  terminated  in 
his  death  was  engrafted  on  a  pre-existing  mental  disorder, 
it  became  established  more  strongly  after  obtaining  an  ac- 
count of  his  past  history,  through  an  article  which  appeared 
in  one  of  the  daily  papers  the  day  after  his  death.  It  read 
as  follows:  "David  Wemyss  Jobson  died  of  paralysis,  on 
Friday  last,  in  the  Ward's  Island  Hospital  for  the  Insane. 
He  was  about  seventy  years  of  age.  His  body  was  taken 
to  the  morgue  yesterday,  and,  if  not  claimed  to-day,  the 
commissioners  will  inter  it  to-morrow  in  the  Potter's  Field 
on  Hart's  Island.  Letters  found  among  his  effects  show 
that  he  was  born  in  Dundee,  Scotland,  of  a  family  that  had 
been  landholders  for  centuries.  He  graduated  at  the 
Edinburgh  University   in   1827,  and  studied  both  surgery 


346  INSANITY. 

and  dentistry.  About  1836  he  settled  in  London,  and  ob- 
tained permission  from  King  William  IV.  to  call  himself 
Surgeon  Dentist  to  the  King,  and  this  permission  was  sub- 
sequently [also]  accorded  by  Queen  Victoria.  A  year  or 
two  after  the  Queen's  accession  he  gave  offence  by  espous- 
ing intemperately  the  cause  of  the  Lady  Flora  Hastings, 
one  of  her  maids  of  honor,  who  was  afflicted  with  a  form 
of  dropsy,  and  was  wrongfully  said  to  be  about  to  become 
a  mother.  The  lady  soon  died,  and  an  autopsy  disproved 
the  suspicion.  In  consequence  of  Jobson's  partisanship 
the  permission  to  style  himself  Surgeon  Dentist  to  the 
Queen  was  withdrawn,  and  he  lost  much  practice  among 
the  aristocracy.  His  pecuniary  fortunes  declined,  and  he 
obtained  a  precarious  support  by  writing  for  newspapers 
and  magazines.  At  times  he  was  aided  by  remittances 
from  his  relatives  in  Scotland. 

"  At  the  outbreak  of  the  French  Revolution  of  1S48  he 
went  to  France  and  ingratiated  himself  with  Lamartine 
and  other  members  of  the  provisional  government,  and, 
without  any  military  education,  he  managed,  according 
to  his  own  account,  to  obtain  the  honorary  title  of  gen- 
eral.* He  returned  to  London,  and  about  1854  came  to 
the  United  States,  where  he  found  an  indifferent  support 
by  his  pen.  He  became  naturalized,  but  afterward  made 
repeated  voyages  to  England,  and  there  he  continued  to 
write  for  the  press.  There  are  numerous  letters  among  his 
papers  from  the  secretaries  of  Prince  Albert,  Lord  Palmer- 
ston,  the  Earl  of  Derby,  Mr.  Disraeli,  and  others,  thanking 
him  politely  for  documents  sent,  but  expressing  inability 
to  render  them  available  for  any  purpose.  Jobson  was  im- 
prisoned for  a  night  in  London  and  fined  ;!^5o  for  insulting 
Alderman  Gibbs,  while  that  official  was  acting  as  a  magis- 
trate. On  another  occasion  Recorder  Russell  Gurney  sen- 
tenced him  to  hard  labor  in  the  Bridewell  for  libelling  Sir 
James  Ingram.  Sir  Edward  Thornton,  the  British  Minister 
at  Washington,  was  repeatedly  written  to  by  Jobson,  with 
reference  to  panaceas  for  quelling  the  troubles  in  Ireland, 
and  Jobson  received  several  polite  letters  from  him  declin- 
ing to  act  upon  his  suggestions.  In  1858  a  Mr.  Ira  D. 
Jobson,  of  2  Paton's  Lane,  Perth  Road,  Dundee,  Scotland, 
wrote  that  his  uncle  had  died,  leaving  him  and  his  brothers 
about  ;!^4o  apiece,  but  that   David's  name  was  not   men- 

*  This  was  a  fact. 


DIFFERENTIAL   DIAGNOSIS.  347 

tioned  in  the  will.  The  bulk  of  the  property,  he  said,  had 
been  left  to  the  poor  relations  of  the  Earl  of  Camperdown. 
This  took  Jobson  to  England,  and  among  his  papers  is  the 
copy  of  a  memorial  which  he  sent  to  the  Lord  Chancellor 
in  1859,  announcing  his  return  from  America  to  claim  a 
heritage  of  15,000  acres  of  land  that  had  been  in  his  fam- 
ily for  centuries,  and  also  ^^26,000  that  had  been  left  by 
his  uncle  chiefly  to  Sir  James  Ferguson,  nephew  of  Lord 
Camperdown,  who  had  married  his  (Jobson's)  niece.  He 
complained,  also,  that  he  had  been  placed  in  a  lunatic  asy- 
lum by  Sir  James  Ferguson's  machinations. 

"  Having  been  unsuccessful  in  his  application,  Jobson  re- 
turned to  America.  His  career  here  is  well  known.  He 
wrote  casually  for  newspapers,  received  casual  remittances 
of  jQi  at  a  time  from  Mr.  Ira  D.  Jobson,  and  obtained 
credit  where  he  could  for  clothing.  In  the  winter  of  1874- 
75,  he  became  ragged  and  almost  bare-footed,  and  in  March 
last  he  was  taken  to  the  asylum  at  Ward's  Island,  more  out 
of  pity  than  on  account  of  any  danger  occurring  to  the 
public  from  his  harmless  insanity."  Subsequently  the 
writer  was  informed  by  ex-Judge  Joseph  Koch,  that  while 
the  latter  acted  as  police  magistrate  Jobson  frequently 
annoyed  him  by  bringing  complaints  against  the  British 
Government,  and  certain  city  officials  who  had  dealt  with 
him  unjustly  in  reference  to  a  public  candidacy.  Be  it 
known  that  this  patient  had  had  himself  nominated  for 
the  comptrollership  of  this  city  by  an  ephemeral  organi- 
zation, and  had  actually  received  a  number  of  votes  in 
the  ensuing  election.  It  was  also  evident  from  his  own 
account  that  he  had  been  engaged  in  a  riotous  movement  in 
Australia,  and  been  imprisoned  a  year  there  in  consequence. 

While  during  the  earlier  periods  of  his  asylum  sojourn, 
he  enunciated  his  systematized  delusions  of  having  been 
defrauded  of  the  comptrollership,  and  wrote  the  average 
kind  of  newspaper  poetry,  complaining  of  the  machinations 
of  the  British  Government  against  himself,  and,  on  the 
other  hand,  alleging  the  existence  of  conspiracies  against 
that  very  government,  these  elaborate  notions  were  less 
distinctly  announced,  and  most  of  them  even  forgotten, 
some  months  before  his  death,  when,  with  marked  emo- 
tional tremor  and  imperfect  tongue,  he  stuttered  forth  the 
wildest  and  most  inconsistent  ideas  of  aggrandizement, 
mingled  with  complaints  about  the  vermin  alluded  to,  and 
which  evidently  depended  on  the  hyperaesthesia  and  paraes- 


348  INSANITY. 

thesia  which  constituted  marked  features  of  the  physical 
part  of  his  symptoms.  The  autopsy  revealed  marked  cys- 
tic degeneration  of  the  cortex  of  the  paracentral  lobule  and 
of  the  inner  face  of  the  frontal  lobe;  adhesion  of  the  pia 
over  the  central  gyri  and  superior  parietal  lobule  ;  ex- 
tensive atheromatous  degeneration  of  the  arteries,  both  of 
the  great  trunks  and  the  primary  and  secondary  branches; 
atrophy;  fatty,  granular,  and  sclerotic  degeneration  of  the 
cortical  nerve  cells;  as  well  as  similar  and  more  intense 
changes  in  the  cells  of  the  lower  cranial  nerve  nuclei  and 
of  the  anterior  spinal  cornua.  There  was  no  deviation 
from  the  normal  convolutional  type  as  such,  but  the  writer 
has  never  seen  the  transverse  type  of  corrugation  of  the 
gyri  as  pronounced  in  any  human  brain  as  in  this  one  ;  the 
skull  was  moderately  stenotic  ;  the  pons  and  oblongata, 
the  latter  particularl}',  were  unusually  small,  but  this  could 
be  referred  to  the  diffuse  sclerosis  and  atrophy,  of  which 
these  parts  were  the  seat. 

An  analogous  case  is  that  of  a  Doctor  P e,  who  was 

observed  at  the  same  institution,  and  in  whose  case  there 
was,  about  thirty  years  ago,  a  history  of  erotic  monomania 
from  which  he  emerged  with  the  systematized  and  well- 
defended  delusion  that  he  was  King  George  the  Fourth. 
During  the  time  the  writer  observed  him,  he  gradually 
developed  all  the  physical  signs  of  paralytic  dementia,  even 
to  its  trophic  disturbances;  but,  though  hardh'^  able  to  articu- 
late, and  unable  to  defend  his  delusions,  he  still  held  to  his 
royalty,  and  insisted  on  the  honors  due  the  latter  in  a  vague 
and  unintelligent  way,  in  marked  contrast  with  his  previous 
plausible  and  linked  reasoning  on  the  same  subject. 

While  the  combinations  of  symptoms  characterizing  the 
special  forms  have  been  described  in  the  second  part  of 
this  work,  and  need  not  be  repeated,  we  may  here  brief!)'' 
recapitulate  the  special  symptoms  of  insanity,  and  the 
forms  in  which  they  are  likely  to  be  found  in  their  order 
of  probability.* 

I.  Delusions:  A.  Systematized;  a,  fixed  and  permanent:  in 
monomania  (characteristic);  b.  fixed  for  the  time  being  and  in- 
termittent: hysterical  insanit}'',  periodical  insanity  (latter 
rare).     B.    Unsystematized;  a.  creative,  with  elements  of  exalta- 

*  The  complicating  forms  are  omitted  here;  their  association  with  the 
bodily  states  on  which  they  depend  serves  to  characterize  them  in  the 
main,  a  special  analysis  of  them  lies  outside  the  limits  of  this  manual. 


DIFFERENTIAL   DIAGNOSIS.  349 

Hon:  in  simple  mania,  maniacal  exacerbations  of  paretic 
dementia  in  early  stages,  periodical  mania,  hysterical  insan- 
ity; b.  creative,  with  predominating  element  of  depression:  melan- 
cholia, hypochondriacal  and  other  depressive  phases  of 
paretic  dementia,  periodical  melancholia,  chronic  alcoholic 
insanity,  katatonia;  c.  monotonous  and  confused,  with  elements 
of  exaltation:  in  secondary  confusional  insanity,  paretic 
dementia  in  latter  stages,  imbecility;  d.  monotonous  and  con- 
fused, with  elements  of  depression:  in  secondary  confusional 
insanity,  paretic  dementia  in  later  stages,  chronic  alcoholic 
insanity;  e.  monotonous  and  confused,  with  elements  of  depression 
and  exaltation  mingled:  m  acute  confusional  insanity,  senile 
dementia,  epileptic  insanity,  katatonia,  insanity  of  pubes- 
cence. 

II.  Hallucinations  and  Illusions:  a.  visional:  in  mono- 
mania, epileptic  insanity,  hysterical  insanity;  I?,  of  single 
or  a  fe7c>  objects  related  to  the  patient's  ideas:  in  simple  melan- 
cholia, simple  mania,  primary  confusional  insanity,  period- 
ical insanity,  paretic  dementia  ;  c.  of  multifarious,  usually 
disagreeable,  objects:  in  alcoholic  insanity,  epileptic  insanity, 
paretic  dementia. 

III.  Imperative  Conceptions  and  Impulses  :  a.  continu- 
ous:  in  monomania,  imbecility;  b.  periodical:  in  periodical 
insanity;  c.  episodical:  in  simple  melancholia,  hysterical  in- 
sanity, paretic  dementia,  monomania,  imbecility. 

IV.  Abulia:  in  simple  melancholia,  prodromal  period  of 
mania  and  paretic  dementia,  alcoholic  insanity,  periodical 
melancholia,  forms  ending  in  general  mental  enfeeblement, 
monomania  with  overwhelming  hallucinations  and  de- 
lusions. 

V.  Hyperbulia:  in  maniacal  phases  of  simple  mania, 
paretic  dementia,  periodical  insanity,  expansive  monomania. 

VI.  Marked  Emotional  Disturbance  :  A.  Without  in- 
tellectual motive;  a.  angry  (i)  simply:  in  maniacal  furor,  pa- 
retic furor;  (2)  angry  afui  treacherous:  in  epileptic,  alcoholic, 
and  paretic  furor;  (3)  angry  and  anxious:  in  melancholic 
frenzy,  transitory  frenzy,  katatonia ;  /'.  expansive,  good- 
humored,  or  pleasurable:  in  simple  mania,  paretic  dementia, 
periodical  mania;  c.  depressed,  sad,  or  anxious:  in  simple 
melancholia,  periodical  melancholia,  alcoholic  insanity,  ep- 
ileptic insanity,  paretic  dementia  in  early  stages,  katatonia, 
insanity  of  pubescence.*     B.    With  intellectual  motive;  a.  an- 

*  This  is  also  the  order  of  the  depth  of  the  emotional  disturbance. 


350  INSANITY. 

gry  and  expansive:  in  episodical  delirium  of  monomania;  i. 
depressed:  in  prodromal  period  of  mania,  monomania  with 
depression,  primary  deterioration. 

VII.  Impaired  Consciousness,  of  a  Marked  Degree  and 
Demonstrable  Kind  :  in  epileptic  insanity,  transitory 
frenzy,  stuporous  insanity,  melancholic  frenzy,  alcoholic 
frenzy,  delirium  grave,  maniacal  and  paretic  frenzy,  cata- 
leptic phases  of  katatonia. 

VIII.  Mental  Weakness  Prominently  Developed  :  a. 
itivolving  the  mental  faculties  generally:  idiocy,  imbecility,  pri- 
mary deterioration,  dementia — whether  terminal,  epilep- 
tic, alcoholic,  or  from  organic  disease — delirium  grave;  h. 
with  '^ focal"  lacunce:  paretic  dementia,  syphilitic  dementia, 
chronic  alcoholic  insanity,  secondary  confusional  insanity, 
primary  confusionalinsanity,  insanity  of  pubescence. 

IX.  Mental  Weakness  extending  in  Limited  Direc- 
tion :  monomania. 

X.  Marked  Amnesia,  aside  from  Unconsciousness  :  in 
epileptic  insanity,  delirium  grave,  paretic  dementia,  syphi- 
litic dementia,  senile  dementia,  dementia  from  organic 
disease,  chronic  alcoholic  insanity,  terminal  dementia, 
chronic  confusional  insanity. 

XI.  Somatic  Stigmata:  in  idiocy,  cretinism,  imbecility, 
monomania,  epileptic  insanity,  periodical  insanity,  hyster- 
ical insanity,  exceptionally  and  then  non-essential  in  all 
other  forms. 

XII.  Active  Disturbance  of  the  Bodily  Functions: 
in  delirium  grave,  melancholia,  stuporous  insanity,  mania, 
katatonia,  frenzy,  initial  and  terminal  periods  of  paretic 
dementia,  senile  dementia,  monomania  with  hypochondri- 
acal or  persecutory  delirium. 

XIII.  Special  Trophic  Disturbances:  in  delirium  grave, 
paretic  dementia,  syphilitic  dementia,  dementia  from  or- 
ganic disease,  epileptic  dementia,  melancholia,  terminal 
dementia. 

XIV.  Positive  Disturbances  of  Locomotion  :  in  pa- 
retic dementia,  syphilitic  dementia,  delirium  grave,  de- 
mentia from  organic  diseases,  epileptic  insanity,  alcoholic 
insanity. 

XV.  Speech  Disturbances:  a.  acquired:  in  paretic  de- 
mentia, syphilitic  dementia,  dementia  from  organic  disease, 
alcoholic  insanity;  b.  congenital :  idiocy,  imbecility,  mono- 
mania. 


DIFFERENTIAL   DIAGNOSIS.  35  I 

XVI.  Tremor:*  a.  senile  dementia,  alcoholic  insanity, 
dementia  from  organic  disease  (multiple  sclerosis),  paretic 
dementia,  syphilitic  dementia,  epileptic  insanity;  b.  true 
emotional  tremor,  any  form  with  high  neural  excitement  such 
as  mania,  frenzy,  monomania  with  episodical  deliria. 

XVII.  Oddities  of  Speech:  a.  echolalia:\  in  imbecility,  in- 
sanity of  pubescence,  dementia,  imbecility;  b.  verbigeration: 
in  katatonia,  epileptic  insanity,  hysterical  insanity,  chronic 
confusional  insanity,  insanity  of  pubescence;  c.  rhyming:  in 
katatonia,  insanity  of  pubescence,  epileptic  mental  states, 
sometimes  in  any  episodical  excitement. 

XVIII.  Convulsions  :  in  epileptic  insanity,  paretic  de- 
mentia, syphilitic  dementia,  dementia  from  organic  disease, 
katatonia,  an  accidental  accompaniment  of  other  forms. 

While  but  the  main  disturbances  are  detailed  in  this 
schedule,  the  latter  will  serve  as  a  guide  to  a  provisional 
diagnosis  at  least,  following  the  plan  detailed  in  the  two 
hypothetical  cases  detailed  above  (p. 342).  Suppose  that  a 
history  of  a  convulsion  or  convulsive  movement  is  given  in 
connection  with  mental  disturbance  ;  it  may  according  to 
the  schedule  be  an  evidence  of  four  mental  states.  The  most 
frequent  form  with  convulsions  is  epileptic  insanity;  if  now 
a  confused  delirium  of  a  partly  aggressive  and  depressive 
character  (I),  hallucinations  of  multifarious  and  disagree- 
able objects  (II),  angry  and  treacherous  excitement  (VI), 
impaired  consciousness  (VII),  positive  disturbances  of  loco- 
motion (XIV),  and  verbigeration  (XVII)  are  found,  the  physi- 
cian may  positively  pronounce  the  case  one  of  epileptic 
insanity.  And  this  he  may  do  if  only  a  majority  of  the 
signs  enumerated  are  present,  if,  as  is  sometimes  the  case, 
the  hallucinations  are  agreeable,  if  there  is  no  motor  distur- 
bance and  no  verbigeration  ;  for  the  symptom  combinations 

*  We  are  not  yet  able  to  differentiate  by  clinical  signs  all  the  varieties 
of  tremor  encountered  among  the  insane;  the  possibility  of  confounding 
the  tremor  due  to  excessive  smoking  with  that  of  alcoholism  should  be 
therefore  borne  in  mind.  There  are  certainly  some  smokers  whose 
tremor  cannot  be  distinguished  from  that  of  paretic  dementia;  indeed 
there  are  reasons  for  supposing  that  nicotine  may  affect  the  central  ner- 
vous apparatus  in  a  similar  direction.  Paretic  dementia  has  become  very 
frequent  among  Austrian  army  officers,  owing  to  their  habit  of  consum- 
ing large  quantities  of  what  they  term  "Virginia  segars."  These  are 
perforated  by  a  reed,  so  that  the  smoke  is  not,  as  in  the  ordinary  rolled 
weed,  deprived  of  most  of  its  deleterious  ingredients. 

\  Echolalia  is  the  thoughtless  repetition  of  words  and  phrases  spoken 
by  others,  the  subject  not  associating  any  mental  conception  with  them. 


352  INSANITY. 

of  the  other  forms  associated  with  convulsions  are  alto- 
gether different,  and  do  not  coincide  except  in  unimportant 
details  wfth  those  of  epileptic  insanity. 

Among  the  evidences  aiding  in  the  differential  diagnosis 
of  the  various  psychoses  are  the  age,  sex,  heredity,  and 
vocation  of  the  patient.  A  man  at  forty  cannot  be  a  pubes- 
cent lunatic  (though  he  may  have  begun  as  one),  nor  a 
senile  dement.  A  female  is  less  likely  to  suffer  from  pa- 
retic dementia  than  a  male,  and  a  male  less  likely  to  be  a 
periodical  lunatic  than  a  female.  A  patient  with  insane 
ancestors  is  more  likely  to  suffer  from  the  psychoses  asso- 
ciated with  a.  neurotic  taint,  than  one  whose  ancestry  is 
free  from  insanity.  A  Wall-street  speculator  is  more  likely 
to  be  a  paretic  dement  than  a  farmer.  But  these  facts  are 
of  relatively  slight  value,  and  merely  collateral  to  those 
enumerated. 

Where  the  diagnc^is  of  a  special  form  of  insanity  cannot 
be  made,  the  alienist  is  compelled  to  limit  himself  to  the 
question  of  the  existence  of  insanity  in  general.  To  deal 
with  so  obscure  a  case,  all  his  diagnostic  acumen  must  be 
employed.  It  is  then  neither  hallucinations,  delusions, 
motor  disturbances,  nor  amnesia  that  lie  on  the  surface 
and  indicate  the  line  of  examination  to  be  followed.  He 
must  test  for  pyschical  weakness  in  the  abstract,  for  ab- 
normal irritability,  logical  perverseness,  abulia,  hyperbulia, 
lack  of  reaction,  and  abnormal  emotional  states,  whose 
characters  language  cannot  portray,  so  that  they  can  be 
appreciated  in  the  living  subject  only. 


CHAPTER  III. 

The  Recognition  of  Simulation. 

The  psychological  diagnostician  has  less  frequently  to 
deal  with  the  feigning  of  insanity  by  the  sane  than  with  the 
dissimulation  or  concealment  of  insanity  by  the  insane. 
Persons  who  have  once  been  inmates  in  an  asylum,  those 
who  have  sufficient  mind  to  know  the  meaning  of  a  medical 
examination,  and  particularly  those  who  have  an  occasional 
glimpse  of  the  fact  that  they  are  considered  insane,  or  in 


THE   RECOGNITION   OF   SIMULATION.  353 

part  recognize  their  insanity  themselves,  are  frequently- 
very  difficult  to  examine.  For  however  much  the  alienist 
may  become  satisfied  from  the  expressions,  the  manner  and 
histories  of  such  patients,  that  they  are  insane,  they  obsti- 
nately conceal  those  symptoms  which  it  is  desirable  to  dis- 
cover for  the  purpose  of  satisfying  the  legal,  or  it  may  be 
the  medico-legal,  demands  of  a  commitment  or  an  exami- 
nation undertaken  for  forensic  purposes. 

Simulation,  although  far  from  uncommon,  is  not  as  often 
resorted  to  as  some  writers  would  like  the  public  to  believe 
in  order  to  facilitate  the  reception  of  testimony  "arranged  " 
to  suit  the  demands  of  public  prejudice  and  of  medico- 
legal conspiracies.  Historical  instances  of  simulation  are 
cited  in  the  various  treatises  on  insanity,  and  it  seems  that 
the  history  of  feigned  mental  disease  is  almost  coeval  witii 
the  authentic  history  of  the  human  species.  It  was  known 
to  Homer,  who  describes  Odysseus  as  feigning  insanity  to 
achieve  a  special  purpose.  Solon  shammed  insanity  in 
order  to  stimulate  the  Athenians  before  Salamis;  and 
David  is  described  in  the  Bible  as  feigning  dementia,  and 
resorting  to  the  same  artifices  which  are  employed  to-day 
by  those  simulating  that  condition.  As  might  be  antici- 
pated, insanity  has  been  feigned  for  special  and  usually 
selfish  purposes.  Such  nobler  objects  as  that  of  Brutus,  who 
escaped  persecution  and  threw  sand  in  the  eyes  of  the 
Tarquins,  in  behalf  of  Rome  by  this  means,  cannot  be  carried 
out  by  the  aid  of  simulation  in  the  present  state  of  society. 
To-day  it  is  usually  resorted  to  by  criminals  who  have  no 
other  hope  of  escape  from  punishment  than  the  "insanity 
dodge";  by  persons  desirous  of  annulling  contracts  which 
they  regret  having  made,  and  which  they  hope  to  have  set 
aside  by  proving  mental  incompetency  at  the  time  of 
making  them;  and  by  sensation-seeking  and  enterprising 
newspaper  reporters  who  desire  to  enter  asylums  and  to 
"investigate"  their  management.*  The  possibility  of  pro- 
longed simulation,  as  a  step  to  the  contemplated  commis- 
sion of  a  crime,  by  a  calculating  criminal,  must  also  be 
borne  in  mind. 

*  Kiernan  detected  a  newspaper  reporter  who  had  had  himself  com- 
mitted to  the  workhouse  as  a  pauper,  and  there  shammed  insanity  and 
secured  his  transfer  to  the  City  Asylum  for  the  purpose  of  publishinaf  the 
abuses  which  there  was  reason  to  believe  were  enacted  there.  One  re- 
porter remained  an  inmate  for  nearly  half  a  year  at  the  Bloomingdale 
Asylum  without  detection,  and  accomplished  his  purpose  to  the  fullest 
extent. 


354  INSANITY. 

The  subject  of  the  simulation  of  insanity  offers  for  the 
alienist's  consideration  two  very  distinct  branches:  the  first 
is  the  simulation  of  insanity  by  ignorant  persons;  the  sec- 
ond the  simulation  of  insanity  by  persons  who  have  had 
opportunities  for  studying  or  observing  insanity.  In  the 
former  case,  detection  is  easy;  in  the  latter  it  is  more  or 
less  difficult;  and  there  are  instances  on  record  where  the 
best  alienists  have  been  puzzled  or  deceived  by  simulators 
whose  skill  in  feigning  reached  the  degree  of  the  most 
consummate  acting,  and  must  have  been  based  on  skilful 
observation.*  The  truly  wonderful  power  of  endurance 
manifested  by  some  simulators  renders  their  exposure  a  far 
more  difficult  task  than  it  is  commonly  supposed  to  be. 
Thus  Vingtrinierf  relates  the  case  of  one  Picard  who  had 
been  guilty  of  fraudulent  bankruptcy  and  then  shammed 
insanity  for  five  years.  The  same  person  had  previously 
simulated  incontinence  of  urine  for  an  entire  year,  in  order 
to  exempt  himself  from  military  service,  and  persisted  in 
this,  although  his  comrades  in  the  barracks  resorted  to 
various  and  even  cruel  devices  to  check  his  disagreeable 
habit.  The  publicity  of  trials,  and  the  full  reports  of  ex- 
pert and  pseudo-expert  testimony  given  to  the  public  in 
the  daily  papers,  are  adding  not  a  little  to  the  difficulties  of 
the  subject.  Our  skill  in  the  detection  of  simulation  is  in- 
creasing from  year  to  year,  but  the  skill  of  the  simulator  is 
also  increasing.  Shortly  after  the  Gosling  and  Prouse 
Cooper  trials  in  New  York  City,  a  noted  criminal  lawyer  of 
the  lowest  possible  morale  instructed  a  defrauding  lawyer, 
who  had  been  formerly  a  medical  student,  to  feign  paretic  de- 
mentia, and  so  far  from  overdoing  matters — the  fault  of  most 
simulators — the  latter  limited  himself  strictly  to  acting  the 
symptoms  of  the  prodromal  period  of  that  disorder  to  the 
best  of  his  ability. 

It  was  at  one  time,  and  is  still  with  some,  a  commonly 
received  test  that  the  simulator  does  not  repudiate  the 
idea  of  being  insane,  which  the  truly  insane  person  does. 
Aside  from  the  fact  that  the  insane  do  sometimes  recog- 
nize   their    insanity   and    exceptionally    admit    it,f    which 


*  Ollivier.  Jacquemin,  Ferrus  and  Marc  were  thus  completely  deceived 
bv  the  simulating  murderer  Gilbert,  and  even  Esquirol  at  one  time  sus- 
pected him  to  be  insane.  To-day,  however,  the  writer  believes,  the 
shamming  of  such  a  person  would  not  have  proven  as  successful. 

+  Ann.  d'hygiene  publique  et  de  medecine  legale,  1853. 

t  Seventeen  patients,  suffering  from  well-marked  forms  of  insanity,  in. 


THE   RECOGNITION   OF   SIMULATION.  355 

alone  should  have  forbidden  the  adoption  of  so  faulty  a 
criterion,  it  is  to-day  valueless  because  many  simula- 
tors know  or  believe  it  is  considered  such  a  test,  and  af- 
fect to  disclaim  the  existence  of  the  malady  which  they 
wish  to  have  imputed  to  them.*  That  they  overdo  this, 
as  well  as  other  manufactured  symptoms  of  derangement, 
is  but  consistent  with  the  general  character  of  the  simu- 
lator. Derozier,  whose  interesting  case  is  cited  from 
Morel  by  Laurent — after  such  simulator-like  answers  as 
"245  francs,  35  centimes,  124  carriages  to  carry  it,"  in  re- 
sponse to  the  question,  what  his  age  was — being  asked 
"  Has  your  head  been  long  out  of  order?"  replied,  "  Cats, 
always  cats  .....  I  am  not  insane,  the  insane  don't  turn 
around  ";  he  then  arose  and  turned  around  three  or  four 
times,  as  if  to  give  his  own  assertion  the  lie. 

Usually  the  physician's  attention  is  directed  to  the  possi- 
bility of  the  existence  of  simulation  by  some  inconsistency 
in  the  clinical  picture,  exhibited  or  feigned  by  the  subject 
examined.  Such  clearly  marked  affections  as  those  detailed 
in  the  second  part  of  this  work  are  very  difficult  to  feign 
correctly  in  every  feature,  and  it  is  a  task  requiring  consum- 
mate art  for  a  simulator  to  remain  within  the  true  patho- 
logical boundary-line,  and  not  to  break  through  it  in  the  di- 
rection of  caricature.  But  there  are  some  obscure  and 
mixed  groups,  insufficiently  studied,  and  for  that  reason 
not  well  recognized,  in  which  a  simulator  may  succeed  in 
finding  a  place,  he  imposing  his  symptoms  on  the  physician 
as  signs  of  a  mixed  or  impure  form  of  insanity. 

An  important  step  in  the  determination  of  the  existence 
or  non-existence  of  simulation  is  the  investigation  of  the 
previous  character  of  the  subject  and  the  existence  of  a 
motive  for  simulation.  A  cunning  knave,  whose  history  is 
a  repetition  of  crimes,  is  more  apt  to  have  had  the  idea  of 

eluding  paretic  dements,  periodical  lunatics,  suicidal  melancholiacs,  one 
hallucinatory  monomaniac,  and  one  patient  suffering  from  traumatic 
insanity  with  multitudinous  hallucinations  and  violent  impulses,  con- 
sulted the  writer  at  his  office  for  their  insanity.  This  enumeration  does 
not  include  subjects  suffering  from  incipient  signs  of  paretic  dementia, 
primary  deterioration,  alcoholic  insanity,  melancholia  2sv^  folie  du  doute, 
whose  number  is  far  greater. 

*  This  was  the  case  with  a  business  man  who  had  been  ruined  by  op- 
erations in  Wall  Street,  had  written  numerous  insane  letters  of  a  threat- 
ening character  to  a  leading  operator  in  the  same  line  of  business,  and 
was  subsequently  discovered  to  be  the  author  and  indicted  for  attempt 
at  blackmailing. 


356  INSANITY. 

simulation  suggested  to  liim,  and  to  have  received  instruc- 
tion in  the  art  of  simulation,  than  a  straightforward  per- 
son of  previously  honorable  character,  or  who  has  com- 
mitted his  first  offence.  A  murderer,  ravisher  or  abductor 
is  more  likely  to  sham  insanity  than  a  thief,  because  the 
former's  risks  of  suffering  the  death  penalty  or  of  being  long 
confined  in  jail  are  much  more  serious  than  the  prospect  of 
an  asylum  sojourn  of  at  most  a  few  years,  while  in  the  lat- 
ter case  the  comparison  of  a  sojourn  in  jail  with  the  remain- 
ing in  an  asylum,  involving  as  the  latter  does  the  neces- 
sity of  continuing  simulation  day  and  night,  is  very  apt  to 
result  in  a  choice  of  the  prison  as  the  lesser  evil.  In  coun- 
tries where  the  discharge  from  asylums  is  easily  obtained  and 
prison  discipline  is  rigorous,  prisoners  sometimes  feign  in- 
sanity with  the  object  of  securing  a  change  of  quarters.  The 
idea  that  the  mere  fact  that  a  prisoner  presenting  signs  of 
mental  derangement  is  more  likely  to  be  a  simulator  than  a 
real  lunatic,  and  that  simulation  is  frequent  in  jails,  is,  how- 
ever, an  erroneous  one.  The  French  and  German  statistics 
conclusively  prove  that  simulation  of  insanity  is  rare  among 
prisoners,  and  not  at  all  frequent  among  criminals  in  gen- 
eral.* On  the  contrary,  real  insanity  is  of  comparatively 
frequent  occurrence  in  jails,  and  much  more  common  in 
prisoners  than  in  the  ordinary  population,  for  there  are 
special  moral  causes,  remorse,  isolation,  vexation  and  de- 
spair, which,  added  to  the  physical  stagnation  and  depriva- 
tion of  prisoners,  combine  to  break  down  their  mental 
health. 

Prisoners  of  war  and  recruits  resort  to  simulation  more 
frequently  than  any  other  classes.  The  melancholy  case  is 
related  of  two  French  prisoners  of  war  who  feigned  insan- 
ity for  a  long  period,  with  the  intent  of  escaping  by  this 
means,  and  with  such  success  that  both  ultimately  became 
really  insane.  Most  simulators  who  are  convicted  of  simu- 
lation admit  the  distressing  effects  of  the  constant  strain 
and  effort  on  their  nervous  functions,  and  the  warning  that 
feigned  insanity  may  become  a  real  and  incurable  disordei" 
should  be  conspicuously  written  in  every  prison  corridor. 

*  The  opposite  idea,  entertained  and  diligently  disseminated  among  the 
public  on  the  occasions  when  "  popular"  testimony  can  be  safely  given, 
finds  its  expression  in  the  writings  of  an  asylum  physician — it  would  be 
unfair  to  say  an  alienist — who  pronounced  at  least  two  murderers  sane 
and  shamming  (one  of  them  without  any  personal  examination),  in  both 
of  whom  gross  and  extensive  disease  of  the  brain  was  iound  />ost  mortem. 


THE   RECOGNITION   OF   SIMULATION.  357 

It  is  known  of  other  feigned  disorders,  such  as  epilepsy  and 
traumatic  tremor,  that  they  may,  if  persisted  in,  develop 
into  the  real  affections,  and  the  analogous  causation  of 
actual  insanity  by  simulation  is  no  more  problematical 
and  just  as  plausible  as  that  of  the  nervous  disorders  men- 
tioned. 

Very  strange  motives  are  occasionally  observed  to  under- 
lie simulation.  Laurent  speaks  of  former  asylum  patients 
who,  after  their  discharge  as  recovered,  shammed  insanity 
to  get  back  to  their  old  quarters.  A  still  more  remarkable^ 
case  is  that  of  a  young  girl  who  feigned  insanity  in  order 
to  keep  her  sister — who  was  actually  insane — company. 

The  simulation  of  insanity  by  the  insane  sometimes  fur- 
nishes more  troublesome  problems  to  the  diagnostician 
than  that  of  the  sane.  This  remarkable  combination  of 
real  and  feigned  disease  is  by  no  means  rare.  The  writer 
has  not  seen  a  single  insane  criminal  who  was  not  aware  to 
some  extent  of  the  immunity  to  punishment  which  the 
insane  enjoy,  and  who  might  not  —  as  was  the  case 
with  some — have  feigned  mental  disturbance.*  The  mur- 
derer Dubourque,  who  was  undoubtedly  insane,  feigned 
amnesia  of  his  crime,  and  was  convicted  of  the  feint.     An 

*  Guiteau  has  been  erroneously  supposed  to  have  been  a  simulator. 
From  the  time  he  fired  the  fatal  shot  on  the  President  to  the  moment 
when  the  drop  of  the  gallows  fell,  there  was  not  a  moment  in  his  career, 
not  a  word  said  or  a  deed  done  by  him  that  supported  this  idea.  If  ever 
a  more  consistent  record  of  the  insane  manner,  insane  behavior,  and  in- 
sane language  has  been  made  anywhere  else  in  the  history  of  forensic 
psychology  than  in  the  Guiteau  trial,  the  writer  does  not  know  of  it. 
Guiteau  put  in  the  plea  of  transitory  mental  disturbance,  claiming 
Abrahamic  inspiration.  This  is  no  more  surprising  than  that  an  insane 
lawyer,  whose  practice  had  always  been  in  devious  channels,  should,  with 
the  idea,  under  which  the  prisoner  labored,  of  being  his  own  counsel,  use 
every  means  to  escape  an  impending  fate  and  carry  out  his  "  mission." 
Guiteau  was  unaware  of  the  existence  of  his  real  insanity,  repudiated  it 
consistently,  felt  deeply  insulted  by  that  true  opinion  which  wounded 
his  self-love,  and  did  everything  in  his  power  to  fix  the  noose  around 
his  neck  by  combating  it,  showing  off  his  apparent  "smartness,"  and 
insulting  his  counsel.  At  no  time  did  he  make  the  slightest  pretence  of 
being  or  of  having  been  really  insane,  or  give  himself  the  appearance  of 
insanity,  but,  consistently  with  his  egotism,  he  placed  himself  side  by 
side  with  Abraham  acting  under  an  inspiration,  as  he  claimed  to  be  the 
silent  partner  in  the  firm  of  "Jesus  Christ  &  Co."  It  is  an  indelible 
blot  on  American  psychiatry,  a  blot  for  which  our  real  alienists  are  not 
responsible,  but  which  has  been  made  by  a  combination  of  medical  poli- 
ticians, gynaecologists  and  laymen,  that  in  the  case  of  Guiteau  these  and 
other  of  the  strongest  evidences  of  insanity  were  marshalled  into  line 
as  evidences  of  the  very  opposite  condition. 


358  INSANITY. 

imbecile  and  epileptic  pickpocket  with  marked  somatic 
signs  of  constitutional  defect,  feigned  religious  derange- 
ment, and  succeeded  in  obtaining  a  change  of  locality  from 
the  penitentiary  to  the  asylum.  Whenever  the  physicians 
came  into  the  ward  he  dropped  down  on  his  knees  in  an 
attitude  of  profound  religious  meditation,  but  at  no  other 
time.  An  imbecile  murderer  who  presented  the  type  of 
Kalmuck  idiocy  w^hen  arraigned  for  trial,  knowing  that  his 
defence  was  to  be  insanity,  tied  a  cloth  around  his  head 
and  buried  the  latter  in  his  hands,  associating  the  vague 
idea  of  assisting  his  counsel  and  the  medical  witnesses  ap- 
pearing in  his  behalf  with  the  supposed  necessity  of  giving 
the  appearance  of  having  a  headache.  Nichols,  of  Bloom- 
ingdale,  according  to  Kiernan,*  observed  a  case  of  simulation 
of  dementia  under  the  advice  of  lawyers,  by  a  delusional 
lunatic,  who  had  committed  murder  in  obedience  to  the 
command  of  the  Virgin  Mary,  appearing  to  him  in  the 
flame  of  a  candle.  Both  the  feigned  and  the  real  insanity 
were  detected,  and  the  latter  was  unmistakable  throughout 
the  patient's  asylum  sojourn.  While  a  number  of  observa- 
tions of  similar  complicated  cases  have  been  collected  in 
Europe  by  Laehr,  Stark,  Delasiauve,  Ingels,  and  Pelman — ■ 
the  last  mentioned  being  led  to  express  the  extreme  and 
erroneous  view  that  all  simulators  are  mentally  abnor- 
mal, Hughes  was  the  first  on  this  side  of  the  Atlantic  to 
direct  attention  to  this  subject.  This  authority  says  : 
"  The  insane  appear  at  times,  when  they  have  an  object  to 
accomplish,  more  crazy  than,  and  different  from  what  they 
really  are  ;  this  is  the  sense  in  which  we  use  the  term  simu- 
lation, and  this  condition  is  akin  to  that  of  feigning  by  the 
sane.  Simulation,  while  it  presupposes  a  degree  of  san- 
ity,! does  not  require  that  the  patient  should  be  wholly 
sound  in  mind,  and  it  might  be  attempted  by  a  convales- 
cent patient  not  thoroughly  recovered,  or  desirous  of  re- 
maining longer  in  the  hospital,  or  for  some  other  cause." 
That  this  does  occur  is  supported  by  several  cases  ob- 
served by  the  author  cited,  and  by  another  referred  to  in 
thefirst  part  of  this  volume  (page  34).  There  is  not  a 
single  case  on  record  in  which  a  lunatic  who  simulated  in- 
sanity recognized  his  real  disorder. 


*"  Simulation  of  Insanity  by  the  Insane."     Alienist  ami  Neurologist, 
April,  18S2. 

fit  would  be  more  correct  to  say  "  intelligence"  than  "sanity." 


THE  RECOGNITION  OF   SIMULATION.  359 

The  popular  idea  of  insanity,  which  is  responsible  for  its 
frequent  non-recognition  by  juries,  judges,  and  some  phy- 
sicians, is  also  the  cause  for  the  ignorant  simulator's  failure. 
His  belief  is  that  the  insane  are  either  stark  raving  mad 
and  incoherent  at  all  times  and  on  all  points,  or  that  they 
must  be  in  a  condition  of  fatuity.  If  he  has  read  novels, 
he  will  model  his  insanity  after  that  of  some  romancer 
who  possibly  has  never  seen  a  lunatic,  and  of  course  make 
as  melancholy  a  failure  as  in  any  other  event.  There  are 
five  conditions  in  which  gross  incoherence  is  found  com- 
bined with  excitement — furor,  frenzy,  transitory  insanity, 
febrile  delirium  and  acute  confusional  insanity.  We  know 
that  furor  and  frenzy,  whether  in  the  maniac,  melancholiac 
or  paretic,  must  have  been  preceded  by  a  history  of  other 
mental  signs,  which  it  is  difficult  and  in  fact  impossible  to 
imitate  ;  we  know  that  transitory  insanity  is  rare,  of  brief 
duration,  and  coupled  with  amnesia,  and  that  the  patient 
pays  no  rational  regard  to  his  surroundings  during  the  at- 
tack.* Febrile  delirium  is  associated  with  somatic  phe- 
nomena which  a  simulator  could  not  even  approach  imi- 
tating. The  feigning  of  acute  confusional  insanity  alone 
presents  any  chances  of  success,  on  account  of  the  unessen- 
tial character  of  the  physical  phenomena,  the  greater  ease 
of  imitating  the  incoherence  of  this  disorder,  and  the  ab- 
sence of  that  deep  emotional  condition  which  the  simu- 
lator of  mania  and  melancholia  usually  fails  to  take  into 
account.  But  even  here,  as  elsewhere,  the  delirium  of 
the  simulator  has  specific  characters.  Real  raving  ma- 
niacs, if  utterly  incoherent,  show  the  expression  and  so- 
matic signs  of  their  condition  ;  in  milder  raving  there  is 
some  connection  of  the  thought  with  the  surroundings;  in 
simulated  raving  there  is  usually  none.  If  a  confusional  or 
mildly  maniacal  patient  stops  to  answer  a  question,  which 
he  usually  does,  he  answers  it  with  some  degree  of  respon- 
siveness. If  asked  his  age,  he  will  answer  reasonably  or 
err  a  little  but  never  absurdly.  He  may  assign  a  very 
great  age,  or  a  very  much  lower  age  than  his  real  one,  ac- 
cording as  his  tendencies  are  in  the  direction  of  megalo- 
mania or  of  micromania,  but  he  will  never  say,  as  Derozier 
did:  "245  francs,  35  centimes,  124  carriages,  to  carry 
them  away."     These  incoherent  phrases  might  have  come 

*Schwartzer,  "Die  transitorische  Tobsucht"  relates  a  case  of  simu- 
lated transitory  frenzy. 


360  INSANITY. 

from  a  confusional  lunatic,  but  not  as  answers  to  such  a 
question  :  there  is  too  much  method  in  madness  to  permit 
of  such  absurdities  ! 

As  a  rule,  the  simulator  in  those  quiet  periods  of  his 
artificial  excitement  which  are  the  expression  of  inability 
to  keep  up  the  exacting  effort  of  simulation,  does  not 
recognize  his  friends,  his  surroundings,  or  recollect  any- 
thing that  occurred  about  that  period  of  time  which  he  has 
a  motive  to  make  people  believe  he  was  irresponsible  in. 
The  true  maniac,  however,  happens  to  be  lucid  in  those  very 
periods,  recollects  his  family  and  his  friends  perfectly  well, 
and  if  he  has  committed  a  crime,  while  he  may  be  acute 
enough  to  desire  to  conceal  his  recollection  of  it,  he  will  not, 
if  the  examination  is  led  up  to  the  period  of  its  commission, 
gradually  claim  to  forget  real  circumstances  occurring  be- 
fore and  after  it,  as  the  simulator,  who  is  always  on  his 
guard,  does.  It  is  only  in  epileptic  mania  and  in  paretic 
dementia  that  such  amnesia  really  occurs;  but  here  the 
physical  signs  or  the  history,  or  both,  present  us  with  un- 
mistakable signs  of  these  affections  if  they  really  exist. 

The  simulator  also  errs  generally  in  allowing  his  feigned 
disorder  to  explode  as  well  as  to  recede  too  rapidly.  As  a 
rule  the  psychoses  develop  gradually:  those  that  do  not,  have 
certain  characteristic  features  unknown  to  simulators.  Thus 
transitory  frenzy  is  characterized  by  a  noticeable  impair- 
ment of  consciousness,  and  epileptic  mania  by  the  peculiar 
physical  appearance  and  condition  as  well  as  the  history  of 
the  patient.  Outbreaks  of  furor  in  paretic  dementia  may 
occur  quite  suddenly  in  a  remission  or  in  the  prodromal 
period  when  the  patient  is  not  supposed  to  have  been  insane 
by  the  laity;  but  the  distinguishing  marks  of  this  furor  and 
the  accompanying  physical  signs  are  too  numerous  and  the 
residual  state  too  characteristic  to  be  ever  confounded  with 
simulation  by  the  expert.  Sudden  recovery  is  also  suspicious, 
but  not  as  much  so  as  a  sudden  incubation  of  the  malady. 
Mania  has  been  known  to  disappear  by  a  crisis,  and  men- 
strual insanity  in  exceptional  instances  gives  way  almost 
like  a  flash  while  the  disorder  is  apparently  at  its  height. 

Another  characteristic  feature  with  many  simulators  is 
the  intensification  of  their  symptoms  when  under  examina- 
tion. A  simulator  will  become  more  incoherent  or  de- 
mented and  excited  or  obtrusive  with  all  his  symptoms 
when  the  physician  approaches,  than  at  any  other  times,  for 
he  has  a  motive  in  bringing  his  symptoms  to  notice.     Some- 


THE   RECOGNITION  OF   SIMULATION.  361 

times  the  approach  of  the  physician  or  of  any  one  else  will 
irritate  real  lunatics,  but  not  beyond  the  limits  of  a  diseased 
condition  which  is  as  recognizable  in  the  interim  as  in  the 
explosion.  Then,  too,  if  the  mental  capacity  of  the  simu- 
lator is  questioned  in  his  presence  he  will  do  all  in  his 
power  to  strengthen  the  physician  in  what  he  sup]:)oses  to 
be  the  latter's  belief,  while  the  real  lunatic,  unless  sunken 
in  abject  dementia,  will  try  to  show  a  mental  capacity 
which  he  has  not,  and  to  appear  better  than  he  is  ; 
this  attempt,  as  so  old  an  author  as  Hoffbauer  knew, 
only  makes  the  real  lunatic  appear  the  more  deprived  of 
reason.*  That  author  refers  to  the  case  of  a  melancho- 
liac  who  having  a  relapse  of  his  melancholia,  did  the  most 
extravagant  things  not  natural  to  his  illness  in  order  that 
the  relapse  should  not  be  expected  to  have  occurred.  It  is 
in  the  nature  of  the  case  that  the  real  lunatic  suffering  from 
those  forms  of  insanity  from  which  the  simulator  is  most  like- 
ly to  select  his  model  when  he  tries  to  appear  sane,  not  being 
able  to  appreciate  and  to  assume  the  sane  character  should 
show  his  mental  infirmity  only  the  more  prominently.  The 
simulator,  on  the  other  hand,  not  being  able  to  appreciate 
or  to  assume  the  insane  character,  reveals  the  sham  charac- 
ter of  his  malady  the  more  he  rants  and  acts  the  madman. 

The  simulator  also  labors  under  the  mistaken  impres- 
sion f  that  the  insane  do  not  reason.  It  so  happens  that  too 
great  a  degree  of  incoherence  in  a  delusion  justifies  the 
alienist  in  suspecting  its  genuineness.  To  that  kind  of 
delusions  which  the  simulator  undertakes  to  imitate,  the 
statement  that  there  is  method  in  madness  preeminently 
applies.  The  simulator  makes  the  common  mistake  of  be- 
lieving that  insanity  is  a  chaos  of  symptoms,  although  even 
as  a  morbid  condition  it  has  laws  of  its  own. 

Persons  who  feign  a  quiet  form  of  insanity  usually  at- 
tempt to  imitate  dementia.  A  good  case  of  the  failure  of 
this  form  of  simulation  is  one  detailed  by  Snell,  of  a  widow 
who  tried  to  have  a  contract  set  aside,  and  induced  her 
children  to  claim  that  she  had  been  and  was  insane.  Being 
asked  how  many  fingers  she  had  on  her  hand,  she  said  four. 
Being  asked  to  count  them,  she  skipped  one  finger,  and 
said,  "One,  two,  four,  six."     She  further  said  that  two  and 

*  Applies  to  the  forms  of  insanity  which  are  most  likely  to  be  feigned, 
and  not  to  monomania,  hypomania  and  nielancholia  sine  delirio. 

\  Shared  by  several  of  the  prosecuting  experts  in  the  Guiteau  trial. 


362  •  INSANITY. 

two  equalled  six,  that  she  had  nine  children  instead  of 
seven,  that  her  husband  was  dead  ten  years  instead  of  five, 
that  he  died  after  an  illness  of  over  a  week,  when  in  reality 
he  had  died  suddenly  from  an  accident; , gave  the  wrong 
name  to  a  child,  did  not  know  the  number  of  the  year,  nor 
where  she  lived,  though  previously  she  had  admitted  own- 
ing the  very  house  in  which  the  examination  occurred;  and 
when  asked  the  ten  commandments,  said  in  reply  to  ques- 
tions as  to  which  were  the  first  four:  "  ist.  I  am  the  Lord  thy 
God.  2d.  I  am  the  Lord  thy  God.  3d.  I  don't  know. 
4th.  Thou  shalt  not  honor  thy  father  and  thy  mother." 
The  tendency  to  absurd  contradiction,  the  feint  of  forget- 
ting so  important  an  occurrence  as  the  mode  of  death  of 
her  husband,  and  of  simple  things,  in  their  combination  as 
above  shown,  settled  the  fact  that  the  woman  simulated. 
Even  imbeciles  have  some  ideas  within  their  limited  range, 
and  adhere  to  them  with  a  certain  degree  of  consistency 
which  the  simulator  rarely  shows,  and  as  far  as  their  basis 
goes  they  reason  with  a  show  of  logic.  If  a  dement,  not 
absolutely  in  a  state  of  fatuity,  reasons  badly,  there  is  al- 
ways found  confusion  of  words,  while  occasional  glimpses 
of  a  clearer  ideation  struggle  through  ;  the  incoherence 
seems  to  be  due  to  a  digression  from  subject  to  subject,  the 
main  one  losing  its  grasp  on  the  enfeebled  attention  and 
memory.  The  simulator  of  imbecility  or  dementia,  how- 
ever, either  talks  more  confusedly  than  harmonizes  with 
the  thread  of  reasoning  he  unwarily  exhibits,  or  he  talks 
less  confusedly  than  he  should  in  the  utter  absence  of  a 
connecting  bond  in  his  thoughts  ;  in  short,  he  does  not 
balance  the  defects  in  ideation  and  in  their  expression 
properly. 

The  idea  has  gained  ground  that  the  insane  who  have 
amnesia  in  fit-like  spells,  as  in  epilepsy,  alcoholic  insanity, 
and  paretic  dementia,  never  admit  its  occurrence,  while  the 
simulator  is  very  ready  with  the  words,  "  I  don't  remember." 
This  is  true  in  the  majority  of  cases,  but  does  not  apply  to 
the  early  phases  of  paretic  dementia  and  alcoholic  insanity. 
On  the  other  hand,  it  must  be  recollected  that  maniacs  and 
melancholiacs  will  in  their  convalescence  often  attempt  to 
cut  short  inquiries  as  to  their  reminiscences,  by  the  claim 
of  amnesia.  However,  there  is  no  likelihood  of  confound- 
ing these  conditions  with  simulation  of  amnesia  by  the 
mentally  healthy,  for  when  amnesia  is  honestly  claimed, 
and  the  mental  condition  immediately  preceding  and  im- 


THE   RECOGNITION   OF   SIMULATION.  363 

mediately  following  the  alleged  amnesia  carefully  examined, 
something  distinctively  pathological  will  always  be  found. 

The  absence  of  insomnia  and  impaired  digestion  in  the 
acute  psychosis  is  exceptional  in  real  insanity,  and  is,  to 
that  extent,  a  ground  for  suspicion.  These  and  other  dis- 
turbances of  the  bodily  functions  are  not,  however,  char- 
acteristic or  essential  features  of  chronic  insanity,*  al- 
though it  supports  the  idea  that  a  subject  is  really  insane 
when  the  skin  is  in  a  bad  condition,  dry  and  yellow,  or 
moist  and  clammy,  when  there  is  an  effluvium,  when  the 
appetite  is  poor,  the  tongue  coated,  and  the  bowels  are 
constipated.  But  the  physician  who  needs  these  signs  to 
convince  him  of  the  existence  of  insanity,  and  who  would 
elevate  them  to  the  dignity  of  proofs  of  that  condition,  may 
take  his  place  side  by  side  with  those  who  attempt  to  ele- 
vate the  ophthalmoscope  into  a  test  of  insanity  for  medico- 
legal purposes  ;  he  has  not  advanced  much  beyond  the 
position  of  Rush,  who  thought  that  he  could  distinguish 
real  from  feigned  insanity  by  means  of  the  pulse.  This 
claim  could  well  be  made  in  the  earlier  part  of  this  cen- 
tury; only  a  novice  would  rely  on  or  propose  such  tests  to- 
day. 

The  simulator's  task  is  rendered  difficult  whenever  he  is 
kept  under  continuous  observation.  The  best  actor  may 
fail  to  adhere  to  his  assumed  character  for  days  and  nights 
in  succession,  and  the  necessity  of  being  continually  on  his 
guard  gives  the  performance  the  appearance  of  being  la- 
bored. There  are,  however,  instances  recorded  where  the 
first  period  of  simulation  having  been  passed,  it  became  a  sort 
of  second  nature,  and  assumed  an  appearance  of  genuineness 
which  has,  as  stated,  imposed  on  the  foremost  authorities  in 
psychiatry.  The  transfer  of  such  subjects  to  an  asylum  is 
usually  followed  by  a  cure  of  the  insanity,  suspicious  on 
account  of  its  rapidity  and  its  taking  place  in  what  was 
made  to  imitate  an  incurable  form  of  mental  disorder.  It 
is  in  such  cases  that  real  insanity  sometimes  rewards  the 

*  The  condition  of  the  skin  was  the  chief  criterion  on  the  strength  of 
which  an  "expert"  witness  for  the  prosecution  in  the  Guiteau  trial  pro- 
nounced him  a  simulator.  Unfortunately,  the  skin  of  Guiteau,  though  it 
revealed  no  form  of  insanity,  was  m  a  far  worse  condition  than  that  of 
two  thirds  of  the  insane  in  the  institutions  for  the  insane,  to  which  the 
witness  in  question  bore  the  relation  of  a  "consulting  physician"  at  the 
time  of  the  trial.  Psychiatry  is  not  destined  to  become  a  branch  of  Der- 
matology. 


364  INSANITY. 

simulator's  efforts.*  A  ver}'  important  point  to  discover  in 
the  antecedent  history  of  a  suspected  simulator  is  whether 
he  has  ever  had  an  opportunity  of  observing  the  insane,  or 
has  read  treatises  on  the  subject. 

The  devices  for  exposing  simulation  are  numerous. 
Zacchias,  in  consonance  with  the  spirit  of  his  age,  recom- 
mended flagellation;  and  Campagne,  the  douche.  Both 
were  as  wrong  in  believing  that  the  confession  of  having 
played  a  part  or  of  having  attempted  deceit  under  these  cir- 
cumstances has  any  value,  as  the  mediaeval  jurists  were 
wrong  in  believing  that  the  truth  could  be  discovered  by 
means  of  xht  peine  fort  ct  diir.  The  insane  may  be  made  to 
recant  their  delusions,  to  conceal  them,  or,  as  Leuret 
claimed,  even  to  lose  them  under  powerful  motives,  and  it 
would  lead  to  gross  mistakes  to  adopt  any  vigorous  measures 
with  them.  The  torture  of  being  continually  watched,  and 
of  having  to  keep  up  an  unnatural  effort  under  surveillance, 
are  far  more  effective  weapons  for  use  against  simulation, 
and  the  clinical  observation  of  the  really  insane  furnishes 
a  countless  number  of  devices  by  which  the  pretender  can 
be  exposed,  without  involving  the  risk  of  being  inhuman 
to  a  genuine  lunatic  suspected  of  simulation. 

Among  the  special  signs  which  justify  the  suspicion  of 
simulation  are  the  following:  ist.  The  subject  on  the  phy- 
sician's entry  may  avoid  looking  at  him  and  glance  up  at 
the  wall,  and  on  the  physician's  changing  his  place  will  look 
.elsewhere,  demonstrativeh'  avoiding  looking  him  in  the 
face.  This  is  never  the  case  in  stuporous  insanity,  melan- 
cholia, katatonia,  nor  in  apathetic  dementia,  the  forms 
which  a  subject  presenting  these  signs  attempts  to  imitate. 
2d.  The  simulator  will  give  extravagantly  absurd  answers 
to  simple  questions,  after  the  fashion  of  children  in  play 
when  attempting  to  excel  in  saying  impossible  things;  this 
is  in  agreement  with  the  popular  idea  of  insanity.  Derozier 
being  asked  in  June  what  month  it  was,  said  January,  then 
looking  out  of  the  window,  said,  "  Stop,  one  would  say  that 
it  is  warm."  This  alone  sufficed  to  expose  the  sham.  3d. 
The  simulator  may  take  a  long  time  to  answer  questions, 

*  Jacobi  (the  alienist  of  Germany),  in  conjunction  with  Richarz,  Hertz, 
Bocker,  and  Snell,  pronounced  a  subject  to  be  a  simulator,  and  these 
eminent  authorities  were  undoubtedly  right  when  they  did  so.  The  first 
mentioned,  however,  on  receiving  this  person  some  years  after  as  a  real 
lunatic  in  his  asylum,  suspected  that  they  had  all  been  wrong  in  their 
first  opinion.     This  does  not  at  all  follow. 


THE    RECOGNITION   OF   SIMULATION.  365 

and  hesitate  in  his  answers.  Delay  in  answering  and  drawl- 
ing are  found  in  depressed  states,  but  here  the  appearance 
and  expression  harmonize  with  the  exhibition  of  thought 
and  speech,  while  the  simulator's  expression  betrays  an  in- 
telligence which  his  words  are  intended  to  mask.  4th.  The 
simulator  when  he  supposes  himself  unwatched  will  make 
furtive  glances  to  see  whether  any  one  approaches  who 
necessitates  his  being  on  guard.  5th.  A  person  feigning 
epileptic  and  somnambulistic  states  may  recollect  per- 
fectly his  feigned  acts  and  expressions,  and  carry  them  into 
his  (/ uasi  Ivicid  period.  This  never  occurs  in  the  real  affec- 
tions. 6th.  Rhythmical  movements  are  made  by  some 
simulators  which  have  no  analogy  in  insanit)%  or  are  out 
of  harmony  with  the  form  of  mental  disturbance  assumed. 
7th.  Simulators  complain  much  more  about  odd  and  pain- 
ful sensations  in  the  head  than  the  insane  usually  do.  8th. 
A  clumsy  simulator  may  say:  "  I  have  the  delusion  that  I 
am  lost,  that  the  devil  is  after  me,"  or,  "  I  have  hallucina- 
tions of  faces  and  voices  at  night."  Such  a  person  can  be 
readily  exposed  to  be  a  deceiver  on  other  grounds,  but  the 
feature  here  mentioned  alone  suggests  simulation.  A  true 
lunatic  may  admit  that  he  has  hallucinations  and  delusions, 
using  those  words,  especially  when  examined  for  the  pur- 
pose of  being  committed  to  an  asylum,  but  when  he  does 
so  he  affects  to  admit  that  he"  imagined  those  things,"  but 
never  does  a  real  lunatic  at  the  time  he  has  these  symptoms 
give  them  names  which  show  that  he  recognizes  their  ab- 
normal nature.  He  is  lost,  he  is  pursued  by  the  devil,  he 
Aears  voices  and  he  sees  faces.  9th.  It  is  suspicions  if  in- 
sanity appears  immediately  after  a  crime,  or  after  the  arrest 
or  sentencing  of  a  criminal,  while  its  previous  existence  can 
be  disproved. 

The  likelihood  of  simulation  being  combined  with  sanity  is 
very  much  diminished  in  case  the  person  has  already  been 
insane,  and  particularly  if  there  are  somatic  signs  of  heredity 
or  a  history  of  insanity  in  the  blood  relations  of  the  sus- 
pected simulator.  If  such  a  person  feigns,  the  possibility 
of  real  insanity  underlying  the  feint,  must  not  be  for- 
gotten. 

The  devices  which  may  be  legitimately  resorted  to,  to 
expose  simulation  are  the  following:  ist.  When  examin- 
ing the  patient,  let  the  interlocutor  remark  in  an  undertone 
to  a  bystander,  that  if  such  and  such  a  sign  were  present 
he  would  know  in  which  ward  to  put  him,  or  under  which 


366  INSANITY. 

form  of  insanity  to  classify  the  subject.  This  is  far  safer 
than  the  suggestion  adopted  from  the  French  writers  by 
Ray,  and  copied  from  liim  by  some  recent  pamphletists,  of 
saying  tliat  if  such  and  such  a  sign  were  present,  tlie  inter- 
locutor would  believe  the  man  to  be  insane.  This  would  put 
a  cunning  simulator  on  his  guard.  The  writer  had  to  deal 
with  such  a  one  in  the  case  of  a  child  abductor  who  had  feigned 
insanity  in  a  jail  once  before.  Suspecting  that  the  recom- 
mendation of  the  older  writers  would  have  failed,  the  writer 
turned  to  a  bystander  and  said:  "  This  is  a  most  interesting 
case,  and  I  have  frequently  remarked  that  these  patients 
do  not  remember  what  city  they  are  from."  The  criminal 
had  previously  assigned  Baltimore  as  his  home,  and  this 
was,  according  to  the  legal  papers  in  the  case,  correct;  but 
on  being  interrogated  again,  he  said  in  a  hesitating  and 
whining  voice,  altogether  unnatural  to  a  person  suffer- 
ing from  monomania  with  sexual  perversion  (the  form 
claimed  to  exist),  "  Concord,  Cincinnati."  2d.  While  be- 
ing examined  as  to  his  general  sensibility,  the  simulator 
may  believe  that  anaesthesia  is  a  desirable  part  of  the 
clinical  picture;  he  will  wince  when  probed  with  a  pin 
unexpectedly,  but  remain  immobile  when  pricked  after  be- 
ing warned.  This  is,  however,  a  sign  which  is  not  constant 
nor  of  great  value  under  an}'-  circumstances,  though  it  may 
serve  as  a  good  basis  for  an  accusation  of  shamming,  made 
to  test  the  moral  effect  of  the  charge  on  the  simulator. 
3d.  When  a  simulator  is  accused  of  shamming  he  may 
either  turn  away  from  the  examiner,  or  suddenly  lapse  into 
stupor,  or  undergo  some  other  unnatural  change  of  his 
symptoms.  A  real  lunatic  will  either  act  like  a  sane  person 
under  these  circumstances,  or,  as  in  apathetic  states,  show 
no  change  whatever.*     4th.  A  simulator  if  transferred  from 

*  A  writer  whose  inspiration  may  be  found  in  Blandford's  chapter  on 
feigned  insanity,  the  ideas  of  the  latter  being  closely  followed  with  no  other 
change  than  one  of  language,  and  whose  article  opens  with  the  statement 
that  "  moral"  and  "feigned  insanity"  are  convertible  terms,  says  that  "  if 
you  will  accuse  the  simulator  of  shamming,  he  will  scarcely  fail  to 
change  his  countenance."  Now  if  that  writer  had  ever  tried  the  experi- 
ment on  his  own  patients,  he  would  have  found  that  the  few  who  had 
some  relics  of  their  old  pride  left  would  certainly  undergo  a  change  of 
countenance  if  accused  of  humbugging.  Such  a  proposed  test  of  simula- 
tion reveals  the  lack  of  any  searching  and  fair  study  of  insanity  in  some 
of  our  asylums.  With  the  approach  of  insanity,  particularly  of  certain 
forms,  a  person  does  not  lose  all  the  feelings  of  the  normal  human  being, 
and  equally  with  a  sane  person  might  resent  what  he  may  subjectively 


THE   RECOGNITION   OF   SIMULATION.  367 

one  ward  to  another  of  an  asylum,  will  imitate  the  different 
forms  of  insanity  he  sees  there.  He  may  appear  melan- 
choly or  demented  one  week,  hilarious  and  destructive  the 
next,  and  cases  have  been  observed  where  simulators  on 
being  placed  in  the  filthy  ward  of  an  asylum,  with  the  idea 
that  its  disgusting  and  frightful  scenes  would  induce  them 
to  abandon  simulation — which  sometimes  is  the  case — de- 
voured their  own  excrement,  acting  to  the  best  of  their 
ability  as  the  other  inmates  did.  Imitation  may  occur  in 
real  insanity,  but  it  is  limited  to  delusive  conceptions  which 
are  accepted  by  weak-minded  lunatics  from  more  intelli- 
gent ones,  in  what  the  French  caW  foiie  coiiiniu/iique  a.-nd  folie 
a  deux.  A  simulator  whose  signs  indicate,  say,  dementia, 
monomania,  melancholia,  or  mania,  on  being  placed  in  a 
ward  with  paretic  dements  or  epileptics,  allowing  him  to 
overhear  the  statement  that  he  must  be  either  a  paretic  de- 
ment or  an  epileptic,  and  that  he  cannot  possibly  belong 
to  any  other  form  of  insanity,  will  have  delusions  of 
grandeur  and  paralysis  in  the  former  and  convulsions  in 
the  latter  ward.  Numerous  suggestions  may  be  made  of 
symptoms  out  of  harmony  with  the  assumed  mental  dis- 
order, and  their  adoption  serves  to  expose  the  fraud.  Thus 
the  writer  suggested  ptyalism  in  a  simulated  monomania, 
and  oscillatory  movements  of  the  head  in  simulated  sui- 
cidal-iaaaataajiia,  with  this  result.  It  may  be  feasible  to 
relate  cases  in  the  hearing  of  well-posted  simulators,  where 
the  insane  had  miraculous  beliefs,  or  spouted  poetry  all 
day,  and  thus  to  prompt  the  adoption  of  inconsistent  and 
convicting  symptoms. 

Of  the  various  tests  thus  far  enumerated,  the  device  of 
charging  simulation  point  blank  should  not  be  made  until 
all  other  means  have  been  exhausted.  The  simulator 
should  not  know  that  he  is  suspected  until  the  last  mo- 
ment. 

Various  medicinal  tests  have  been  suggested  for  the  pur- 
pose of  exposing  simulation,  but  they  are  of  no  value  ; 
perhaps  the  best  is  ether,  but  comparative  lucidity  may 
occur  after  its  use  in  the  really  insane,  and  both  in  sane 
and  in  insane  persons  false  assertions,  self-accusations, 
and  accusations  against  others  are  made  in  ether  and  chloro- 


regard  as  a  deliberate  insult.  This  ignorance  is  heir  to  the  same  feeling 
which  fifty  years  ago  treated  the  insane  as  wild  beasts,  and  to-day  treats 
them  like  paupers  and  jail-birds. 


368  INSANITY. 

form  narcosis.  The  application  of  the  faradic  wire  brush 
may  expose  a  simulator,  and  this  test  is  a  legitimate  one, 
because  it  is  one  of  the  therapeutical  appliances  indicated 
in  the  treatment  of  those  stuporous  and  atonic  states  which 
are  most  likely  to  be  imitated  by  those  simulators  with 
whom  the  device  may  prove  successful. 

In  analyzing  simulation,  as  in  studying  insanity,  the  in- 
dividual as  a  whole,  his  surroundings,  his  crime,  and  his 
present  mental  state  must  be  taken  into  account.  He  who 
really  has  the  acquired  forms  of  insanity  must  at  some  time 
have  undergone  a  change  of  character;  he  who  suffers  from 
a  congenital  or  inherited  form  must  have  exhibited  mental 
defect  or  disturbance  long  before,  present  somatic  stigmata, 
or  have  an  hereditar}'  history  or  a  neurotic  taint.  The 
crime,  its  motive,  manner  of  commission,  and  the  behavior 
after  the  crime,  are  important  elements  in  the  diagnosis 
between  simulation  and  insanity  in  criminals.  There  are 
some  crimes  which  alone  suggest  insanity,  in  others  the 
motive  and  the  manner  of  commission  demonstrate  its  ex- 
istence.* 

It  is  incorrect  to  conclude  that  because  the  commission 
of  a  crime  involves  deliberation,  premeditation,  and  skill, 
that  it  cannot  be  the  deed  of  a  lunatic.  The  insane,  as  has 
been  repeatedly  urged  by  the  highest  authorities,  and  as 
explained  elsewhere  in  these  pages,  may  reason  very  elabo- 
rately from  false  premises.f  The  simulator  in  cases  where 
his  crime  was  performed  with  skill  and  careful  preparation, 
betrays  his  feint  by  claiming  complete  amnesia,  or  saying 
that  he  must  have  lost  his  head,  by  showing  a  desire  to  appear 
feeble-minded  and  of  weak  memory,  by  representing  his 
family  to  have  been  insane,  or  by  forcing  spurious  insane 
documents  on  the  attention  of  the  observer.  In  short,  the 
false  picture  of  insanity  is  usually  a  caricature,  and  violates 
the  laws  of  insanity  at  almost  every  step  taken  by  the  simu- 
lator, and  in  more  than  one  direction,  in  the  majority  of 
instances. 

*  The  popular  idea  that  the  lunatic  always  slays  openly  is,  however, 
grossly  erroneous;  it  has  been  adopted  as  a  test  of  real  insanity  as  dis- 
tinguished from  simulation,  and  by  a  curious  coincidence,  by  the  very 
medical  witnesses  who  pronounced  Guiteau  a  pretender. 

f  The  possibility  of  a  lunatic's  committing  a  crime  from  the  ordinary 
criminal  motives  cannot  be  denied,  for,  contrary  to  the  statements  of 
those  who  aided  in  the  execution  of  an  assassin  within  the  memory  of 
the  readers  of  this  work,  insanity  does  not  improve  the  morals. 


THE   SOMATIC    ETIOLOGY   OF   INSANITY.  369 

CHAPTER  IV. 

The  Somatic  Etiology  of  Insanity. 

Having  examined  his  patient  and  made  his  diagnosis, 
the  physician's  duty,  before  proposing  remedial  or  other 
measures  in  case  of  insanity,  is  to  inquire  into  its  causation, 
as  the  proper  therapeusis  is  often  guided  by  a  correct 
etiological  assignment.  Naturally  his  attention  is  first 
directed  to  possible  somatic  causes,  as  when  remediable 
they  are  far  more  readily  and  rapidly  remediable  than  the 
mental  causes. 

Nearly  all  the  known  exciting  causes  of  insanity  are  in 
the  nature  of  somatic,  emotional  or  intellectual  accidents, 
to  which  the  sane  population  is  almost  as  much  liable  as 
the  insane.  The  reason  why  insanity  results  in  one  case 
and  not  in  another,  must  therefore  with  certain  exceptions 
be  sought  for  in  some  vice  of  the  constitution — in  other 
words,  in  a  predisposition  to  insanity.  That  this  predis- 
position may  be  acquired  through  traumatism,  syphilis, 
alcoholism  and  other  narcotic  abuses  we  have  already 
learned;  but  the  most  important  predisposing  cause  of  in- 
sanity is  undoubtedly  that  hereditary  transmission  of 
structural  and  physiological  defects  of  the  central  nervous 
apparatus  discussed  in  the  first  part  of  this  work  (page  81). 

As  far  as  the  treatment  of  the  hereditary  transmission  of 
the  defects,  on  which  as  a  basis  insanity  may  develop,  is 
concerned,  it  can  only  be  prophylactic.  And  it  is  left  for  a 
higher  civilization  than  ours,  one  in  which  State  Medicine 
will  no  longer  limit  itself  to  the  quarantining  of  those 
diseases  which  produce  popular  panics,  but  take  cogni- 
zance also  of  those  which  are  more  insidious  and  equally  if 
not  more  destructive  or  damaging  to  the  race,  to  deal  with 
the  great  problem  of  adopting  rational  principles  of  natural 
and  sexual  selection  in  the  propagation  of  our  species. 

To-day  the  practical  alienist  while  regarding  heredity  as 
the  most  prominent  subject  of  inquiry  in  regard  to  the 
etiology  of  insanity,  is  compelled  to  limit  himself  to  the 
study  of  the  acquired  predisposition  and  exciting  causes 
as  the  factors  to  be  considered  in  prophylaxis  and  treat- 
ment.    As  far  as  the  hereditary  predisposition  is  concerned 


370  INSANITY. 

his  advice  will  be  rarely  sought;  and  when  sought,  his 
advice  will  in  the  majority  of  cases  be  limited  to  the 
recommendation  of  educational  methods  adapted  to  the 
case,  and  calculated  to  divert  the  predisposed  mind  into 
channels  which  shall  conduct  it  further  and  further  away 
from  its  threatening  goal.  There  can  be  little  doubt  that 
whether  an  inherited  disposition  exists  or  not,  that  faulty 
educational  systems,  particularly  when  associated  with  the 
hot-house  growing  plan,  may  be  responsible  for  serious 
injuries  to  the  nervous  system  which  may  in  turn  pave  the 
way  for  the  development  of  insanity.* 

Among  the  physical  causes  of  insanity,  head  injuries, 
insolation,  meningitis  and  gross  organic  disease  of  the 
brain  deserve  the  first  consideration,  because  their  in- 
fluence is  directly  and  often  tangibly  applied  to  the  organ 
of  the  mind  or  its  protective  capsule. 

Injuries  of  the  skull  affect  the  mind  in  a  number  of  ways, 
and  while  those  complicated  by  fracture  with  depression, 
are  more  likely  to  lead  to  serious  mental  results  than 
simple  concussion,  yet  even  simple  concussion  may  pro- 
duce chronic  incurable  insanity  or  the  disposition  to  it,  as 
a  number  of  well-observed  cases  attest. 

Sometimes  insanit}'^  is  produced  directly  after  an  injury 
of  this  kind.  Of  this  character  are  the  delirium,  the  hallu- 
cinations and  excitement  often  found  intercurrent  with  the 
sopor  and  coma  following  shock,  and  whose  prognosis  is 
comparatively  favorable.  Sometimes  serious  lacunae  of 
the  memory  are  noted,  and  the  patient  may  lose  the  mem- 
ory of  a  long  period  of  Ms  life  altogether,  either  to  regain 
it,  or  to  pass  into  a  condition  very  similar  to  primary 
mental  deterioration. 

The  most  serious  psychoses  resulting  from  traumatism 
are  developed  months  and  years  after  the  injury.  Some- 
times they  assume  the  character  of  paretic  dementia  (p.  201), 
but  as  a  rule  this  is  not  of  the  pure  type,  and  is  apt  in  the 
prodromal  period  to  be  marked  by  the  furious  outbreaks 
and  murderous  impulses  characteristic  of  what  might  be 
called  the  traumatic  neurosis.  There  is  a  condition  which 
might  be  properly  called  traumatic  insanity^  because  it  does 


*  The  same  applies  to  the  feeding  of  the  mind  on  morbid  fiction,  not  at 
all  a  distinguishing  characteristic  of  the  present  age  by  any  means, 
though  now  cultivated  at  an  earlier  period  of  life,  and  consequently  doing 
proportionately  greater  damage. 


THE    SOMATIC   ETIOLOGY   OF   INSANITY.  37 1 

not  accurately  correspond  to  the  ordinary  psychosis,  has 
distinct  clinical  characters,  and  is  always  when  found,  refer- 
rable  to  traumatism  or  to  analogous  causes;  it  develops 
on  the  basis  of  the  "traumatic  neurosis,"  just  as  alcoholic 
and  epileptic  insanity  develop  on  the  basis  of  the  alcoholic 
and  epileptic  neuroses.  The  subjects  of  this  disorder  are 
noted  to  undergo  a  change  of  character,  to  exhibit  a  ten- 
dency to  alcoholic  excesses,  to  become  morally  perverse, 
suspicious,  brutal  and  quarrelsome,  and  to  manifest  mur- 
derous or  other  violent  impulses,  occasionally  associated 
with  fits  of  maniacal  self-exaltation  or  furor,  usually  of 
short  duration.  This  condition  is  remarkable  for  its  long 
duration  and  its  frequent  and  sudden  changes,  the  occasional 
lucidity  of  the  patients  being  accompanied  at  the  time 
by  hypochondriasis.  As  a  rule  progressive  deterioration 
sets  in,  and  dementia  terminates  the  history  of  the  case. 
The  diagnosis  of  this  condition  is  facilitated  by  the  pres- 
ence of  certain  physical  signs.  Tinnitus  aurium,  photopsia 
scintillation  before  the  eyes,  headache  of  a  pulsatory  or 
grinding  character,  vertigo,  paresis  of  various  muscular 
groups,  particularly  of  the  eye-ball,  without  fibrillary  tre- 
mor, anaesthesias  and  hyperaesthesias,  as  well  as  insomnia, 
are  frequent  accompaniments,  and  some  of  these  enumer- 
ated signs  are  present  in  every  case. 

Insolation  and  the  influence  of  radiant  heat  produce  a 
form  of  insanity  very  much  like  that  due  to  traumatism, 
but  in  the  writer's  experience  these  causes  lead  far  more 
frequently  to  paretic  dementia  than  the  latter.  Firemen 
on  transatlantic  steamers  and  waiters  in  hotels  detailed  to 
duty  in  the  "  plate-warming"  room,  furnish  a  comparatively 
large  quota  to  that  part  of  the  asylum  population  suffering 
from  paretic  dementia  in  New  York. 

The  influence  of  meningitis  on  mental  life  is  well  illus- 
trated in  the  psychical  disturbances,  such  as  delirium,  hallu- 
cinations, depression,  stupor,  and  destructive  impulses 
sometimes  observed  in  the  course  of  tuberculous  and 
simple  meningitis.*     Meynert    believes    that    abortive    or 

*  In  a  patient  dying  with  symptoms  of  paretic  dementia  of  a 
stupidly  delirious  type,  whose  earlier  history  was  unknown — a  fact  that 
may  be  appreciated  when  it  is  known  that  he  was  entered  in  the  asylum 
records  as  John  Doe — chronic  leptomeningitis  traceable  to  a  suppurative 
process  in  the  tympanic  cavity  was  found  post-mortem  by  the  writer. 
The  motor  signs  had  in  this  case  been  well  marked  and  characteristic  of 
the  disorder  diagnosticated. 


372  INSANITY. 

self-limiting  meningitis  in  childhood  may  leave  behind  a 
weakness  of  the  mental  organ,  which  may  manifest  itself 
in  imbecility  with  hallucinations  and  delusions  usually 
accompanied  by  epileptiform  symptoms.  According  to 
that  writer,  a  prolongation  of  the  posterior  cornu  of  the 
lateral  ventricle  beyond  the  normal  length  is  found  in  in- 
sane subjects  who  have  suffered  from  slight  hydrocephalic 
troubles  with  or  without  convulsions  in  infancy,  and  the 
white  substance  in  the  neighborhood  of  the  v6ntricle  often 
contains  sclerotic  patches  in  that  event. 

It  is  scarcely  necessary  in  a  work  of  this  character  to  de- 
tail the  various  cerebral  diseases  which  are  occasionally 
the  causes  of  insanity.  The  general  statement  may  be 
made  that  genuine  derangement  of  the  mental  faculties  is 
more  likely  to  occur  with  multilocular  or  diffuse  than  with 
unilocular  or  circumscribed  lesions,  with  bilateral  than  with 
unilateral  disease,  with  large  than  with  small  foci,  with 
rapidly  developed  than  with  slowly  developed  disturbances, 
with  hemispheral  than  with  axial  affections,  and  with  mor- 
bid changes  established  at  an  early  period  of  life  than  with 
those  affecting  the  brain  after  the  maturation  of  the  mental 
mechanism. 

Next  to  the  organic  affections  of  the  brain  and  its  en- 
velopes it  is  the  neuroses  which  are  the  expression  of  an 
impalpable  brain  disturbance  that  hold  an  important  place 
in  the  causation  of  insanity.  This  influence  has  been  dis- 
cussed in  connection  with  the  clinical  description  of  several 
forms  of  insanity  in  the  second  part  of  this  volume  (Chap- 
ters XVII.  and  XVIII.).  It  remains  for  us  to  speak  here  of 
the  influence  of  chorea  in  the  causation  of  insanity.  In  mild 
cases  of  chorea  the  mind  is  no  more  seriously  affected  than 
in  any  other  affection  annoying  to  children,  and  associated 
with  insomnia.  Even  in  severe  cases  the  mental  faculties 
may  be  found  to  be  quite  intact,*  and  such  disturbance 
as  is  found  in  the  majority  of  cases  is  the  result  of  the 
motor  disturbance  and  of  the  ensuing  restlessness,  irrita- 
bility and  peevishness  of  the  child.  In  protracted  cases  of 
chorea,  the  mind  suffers  in  the  direction  of  actual  insanity; 
in  that  case  maniacal  outbreaks,  confused  delirium,  enfee- 
blement  of  the  memory,  rapid  emotional  change,  and  in  ex- 

*  The  sensational  claim  was  made  at  a  discussion  of  the  subject  at  the 
New  York  Neurological  Society,  that  all  choreic  children  are  morally 
imbecile! 


THE   SOMATIC   ETIOLOGY   OF   INSANITY.  373 

treme  cases  dementia  may  ensue.  It  is  a  psychosis  with  these 
symptoms  which  is  designated  choreic  insanity.  This  dis- 
order must  not  be  confounded  with  another  whose  title 
has  a  similar  sound,  namely,  choreomania.  The  latter  term 
was  given  to  the  epidemic  impulse  to  dance  which  spread  so 
extensively  in  middle  Europe  on  several  occasions  in  con- 
nection with  religious  movements,  and  which  according  to 
Yandell  has  occurred  on  the  occasion  of  a  revival  move- 
ment in  Kentucky  early  in  this  century. 

Fevers  exert  an  important  influence  in  the  production  of 
insanity.  The  term  post-febrile  insanity  is  given  to  dis- 
orders which  complicate  the  crisis,  or  what  would  ordinarily 
be  the  convalescent  period,  of  certain  acute  febrile  processes, 
such  as  scarlatina,  small-pox,  typhus,  typhoid,  pneumonia, 
and  erysipelas.  The  insanity  noted  with  the  secondary 
fever  of  syphilis  appears  to  the  writer  to  belong  to  this 
group  also.  The  post-febrile  pyschoses  are  presumably 
associated  with  two  different  pathological  states,  one  of 
asthenia  and  anaemic  of  the  nerve-centres,  the  other  ana- 
tomically marked  by  the  filling  of  the  periganglionic  and 
subadventitial  spaces  with  formed  elements  of  the  blood. 
As  a  rule,  illusions  and  hallucinations,  delusions  of  identity 
and  anxious  deliria  open  the  scene;  later  there  may  be 
pleasurable  deliria,  or  ideas  of  grandeur.  A  notable 
feature  is  the  comparative  lucidity  of  the  patients  during 
the  day;  they  are  then  able  to  reason  more  clearly,  but,  in- 
asmuch as  they  reason  on  the  basis  of  their  delusive  con- 
ceptions, they  are  all  the  more  dangerous  for  this  lucidity. 
It  is  under  these  circumstances  that  patients  recovering 
from  febrile  disorders  commit  suicide,  usually  by  jumping 
out  of  the  window.  Episodical  attacks  of  violent  frenzy 
may  vary  the  picture.  Most  of  the  patients  suffering  from 
post-febrile  insanity  recover  very  rapidly,  the  psychoses  ter- 
minating with  a  critical  sleep  or  by  gradual  defervescence, 
after  a  course  of  at  most  a  few  weeks.  In  some  cases,  how- 
ever, particularly  after  rheumatic  fever,  scarlatina,  typhus 
and  typhoid,  a  more  chronic  course  is  observed.  The  pa- 
tient's condition  oscillates  between  maniacal  and  melan- 
cholic states,  and  is  characterized  by  great  stupidity  and 
confusion  of  ideas  throughout.  Even  here  the  prognosis 
is  usually  favorable.  In  some,  progressive  deterioration 
sets  in,  and  dementia  ensues;  in  others,  fixed  and  subse- 
quently systematized  delusions  remain  behind,  constituting 
the  case  one  of  delusional   monomania;  morbid   impulses 


374  INSANITY. 

have  been  observed  in  others;  and  in  several  cases,  as  was 
well  illustrated  in  the  instance  of  a  post-scarlatinal  psycho- 
sis, the  subject  of  which  the  writer  exhibited  before  the 
N.  Y.  Neurological  Society,  profound  moral  imbecility  re- 
mains after  the  more  furibund  symptoms  disappear.  Ma- 
larial fever  is  sometimes  accompanied  by  mental  disturb- 
ances which  may  present  a  perfect  imitation  of  cyclical 
insanity,  with  lucid  intervals  corresponding  to  the  period 
between  the  attacks.  A  chronic  mental  disorder,  similar 
to  that  above  referred  to  as  following  other  fevers,  is  also 
noted  as  a  phenomenon  of  the  paludal  dyscrasia.* 

Rheumatic  insanity,  which  is  generally  considered  a  dis- 
tinct form,  has  many  characters  resembling  those  found  in 
the  post-febrile  group  ;  in  cases  where  it  runs  a  chronic 
course,  it  may  terminate  in  paretic  dementia  of  a  kind  whose 
prognosis  is  somewhat  more  favorable  than  it  ordinarily  is 
in  this  disorder.  Other  forms  of  insanity  with  rheumatism 
as  well  as  gouty  insanity,  which  presents  many  analogies, 
are  so  rare  that  they  will  not  be  considered  in  this  manual. 

Anaemia  is  rarely  the  sole  factor  in  producing  insanity; 
usually  other  causes  are  added  to  it.  It  may,  however, 
when  suddenly  produced,  as  after  hemorrhages,  be  the 
single  and  direct  cause  of  stuporous  insanity,  and  is,  in  its 
chronic  form,  undoubtedly  the  most  common  cause  of  this 
variety  of  insanity  in  young  subjects.  As  a  rule  the  anae- 
mia of  other  forms  of  insanity  is  a  result  and  not  a  cause  of 
the  mental  disorder,  particularly  in  simple  melancholia  and 
the  chronic  forms  (p.  69).  In  young  girls  it  is  frequently 
observed  that,  on  the  basis  of  an  anaemia,  there  develops  a 
state  of  mental  anenergy.  Such  subjects  are  prone  to  be- 
come melancholic,  and  in  two  cases  the  writer  has  found  a 
genuine  stuporous  state  following  the  melancholia,  so  that 
there  was  here  a  complication  of  two  different  psychoses. 

The  metallic  poisons  produce  a  mental  derangement 
which,  owing  to  its  frequent  combination  with  motor  dis- 
turbances, may  be  confounded  with  paretic  dementia.  It 
is,  however,  in  its  typical  form  characterized  by  exacerbat- 
ing deliria  of  sudden  development,  and  by  comatous  spells 
of  equally  sudden  occurrence,  which  are   not  found   in   a 

*  In  a  case  of  inherited  malarial  fever,  under  the  writer's  observation, 
the  subject  at  the  a^e  of  from  three  to  five  years  had  a  pleasurable,  good- 
natured  delirium,  with  a  surprisingly  brilliant  flight  of  ideas,  accom- 
panied by  a  rise  of  temperature  (103°  F.),  which  on  several  occasions 
vicariated  for  the  ordinary  febrile  attacks. 


THE   SOMATIC   ETIOLOGY   OF   INSANITY.  375 

similar  association  in  paretic  dementia.  The  specific 
character  of  the  metallic  tremors  will  usually  serve  to  dis- 
tinguish the  psychoses  due  to  hydrargyrism  and  plumbism 
from  the  latter  disease. 

Pulmonary  affections,  particularly  phthisis  in  its  last 
stages,  are  sometimes  marked  by  mental  disorder,  usually 
in  the  way  of  alternating  depression,  emotional  mobility, 
petulance,  an  intensification  of  the  egotism  common  to  in- 
valids, and  accusatory  delirium.  Occasionally  unsystem- 
atized delusions  of  grandeur  are  found  at  the  height  of  this: 
disorder,  which  is  designated  phthisical  insanity. 

Valvular  disease  of  the  heart  is  considered  by  some 
writers,  particularly  Witkowski  and  Leidesdorf,  to  be  a 
frequent  cause  of  depressed  emotional  and  vague  impulsive 
conditions.  The  writer  has  seen  no  confirmatory  example 
of  this,  and  believes  that  the  view  expressed  by  several  of 
the  Germans,  that  hypertrophy  of  the  left  side  of  the  heart 
with  aortic  valvular  lesion  is  more  apt  to  be  associated  with 
maniacal  states,  and  hypertrophy  of  the  right  ventricle 
with  mitral  valvular  lesion  with  melancholic  states,  is  sup- 
ported by  too  limited  a  number  of  cases  to  merit  accepta- 
tion. Those  recorded  are  devoid  of  value,  as  the  blood- 
pressure,  which  is  the  intrinsic  factor,  was  not  duly 
registered.  The  heart  has  important  and  direct  relations 
to  the  brain,  and  it  is  very  likely  that  just  as  disturbances 
of  the  vagus  innervation  are  responsible  for  raptus  melan- 
cholicus — in  other  words,  just  as  a  disordered  state  of  the 
brain  reacts  on  itself  through  the  medium  of  the  functional 
cardiac  disturbance  it  provokes — so  a  valvular  lesion  may 
directly  influence  the  emotional  states  without  pre-existing 
brain  trouble.  When,  however,  we  remember  the  large 
number  of  persons  whose  hearts  are  in  the  most  extreme 
conditions  of  organic  failure,  and  who  die  in  consequence, 
but  without  having  manifested  any  special  psychical  dis- 
order, we  will,  when  we  discover  a  fixed  delusion  of  perse- 
cution in  a  subject,  with  aortic  obstruction,  look  for  some 
other  cause,  such  as  an  insane  predisposition  or  mental 
overstrain,  as  the  primary  determining  element,  while  the  car- 
diac disorder  may  be  admitted  to  act  as  an  exciting  cause, 
or,  more  accurately  speaking,  to  determine  the  anxious 
or  suspicious  character  of  a  delusion.  It  is  a  fact  that 
patients  suffering  from  cardiac  lesions  are  more  likely  to 
develop  anxious  and  suspicious  delusions  than  those  of  an 
opposite  nature. 


376  INSANITY. 

Emminghaus  *  states  that  in  two  cases  of  Basedow's 
disease  (exophthalmic  goitre)  he  found  pronounced  mental 
disturbance  in  the  shape  of  melancholia  and  periodical 
mania.  The  occasional  occurrence  of  this  disorder  in 
members  of  families  afflicted  with  a  morbid  heredity  f 
would  seem  to  indicate  that  the  physical  disease  and  the 
insanity  are  simply  collaterals,  and  that  both  are  the  ex- 
pressions of  the  same  fundamental  neurotic  vice.  It  is  an 
interesting  problem  for  the  future  to  solve  why  enlarge- 
ment of  the  thyroid  gland  should  in  two  disorders  such  as 
exophthalmic  goitre  and  cretinism  be  associated  with  men- 
tal disorder  or  defect. 

Disordered  states  of  the  uterus  and  ovaries,  especially 
those  manifesting  themselves  in  disturbances  of  menstrua- 
tion, have  been  supposed  to  play  an  important  part  in  the 
causation  of  insanity.  It  is  known,  however,  that  the  gross- 
est lesions  of  the  female  generative  organs  are  not  compe- 
tent by  themselves  to  affect  the  mind  to  such  a  degree  as  to 
produce  insanity.  Those  pretty  cases  in  which  a  delusional 
insanity  is  instantaneously  cured  by  restoring  a  retroflected 
or  retroverted  uterus  to  a  normal  position,  do  not  seem 
to  occur  nowadays,  and  the  gynaecological  epoch  of  psy- 
chiatry seems  to  have  passed  by,  taking  its  adieu  with  the 
sacrifice  at  the  Blackwell's  Island  Asylum  of  Mary  Ann 
Mullen,  a  sufferer  from  unrecognized  katatonia,  on  the  altar 
of  oophorectomy. J  It  would  have  been  as  reasonable  to 
extirpate  the  bed-sore  of  a  sufferer  from  paretic  dementia, 
and  to -cut  off  the  haematomatous  ear  of  a  terminal  dement, 
with  the  hope  of  curing  his  insanity  thereby. 

Sudden  stoppages  of  the  menstrual  flow  are  occasionally 
found  to  be  the  direct  causes  of  a  maniacal  attack  in  per- 
sons not  predisposed  to  insanity,  and  the  mechanism  of  the 
psychosis  is  to  be  sought  for  in  the  thus  far  physiologically 
obscure  connection  existing  between  the  uterus  and  ova- 
ries on  the  one  hand,  and  the  encephalic  vaso-motor  sys- 
tem on  the  other.  More  frequently,  persons  affected  by  an 
hereditary  taint  suffer  from  a  periodical  form  of  insanity 
whose  exacerbations  are  determined  by  menstruation,  and 

*Allgemeine  Psychopathologie,  p.  371. 

\A  cousin  of  Guiteau,  now  residing  in  St.  Louis,  was  proven  at  the 
trial  of  the  insane  assassin  to  be  afflicted  with  exophthalmic  goitre.  There 
were  in  three  generations  of  the  family,  among  the  members  whose 
history  is  known,  over  a  dozen  insane  and  defective  individuals. 

X  The  ovaries  were  perfectly  healthy. 


THE   SOMATIC   ETIOLOGY   OF   INSANITY.  377 

in  persons  who  have  what  was  described  in  a  previous  chap- 
ter as  the  monomaniacal  character,  the  delusions  are  often 
greatly  mcKiified  by  the  pelvic  disorder.  Treatment  of  the 
pelvic  difficulty  is  imperatively  demanded  under  these  cir- 
cumstances, and  while  the  pelvic  trouble  is  not  the  funda- 
mental cause  of  the  insanity  in  all  cases  in  which  it  co- 
exists, its  disappearance  is  sometimes  followed  by  great 
mental  improvement. 

The  puerperal  state,  in  the  wider  sense  in  which  Ripping* 
uses  the  term,  has  more  important  relations  to  the  causa- 
tion of  insanity  than  the  other  physiological  periods,  not 
excluding  those  of  the  two  climacterics  and  of  senile  invo- 
lution. During  pregnancy  itself,  peculiar  mental  states  are 
observed,  such  as  morbid  appetites,  varying  from  the  ordi- 
nary//Va  to  anthropophagous  desires;  and  melancholia  is 
comparatively  frequent.  The  greater  frequency  of  the  lat- 
ter condition  in  the  mothers  of  illegitimate  children,  in 
those  who  suffer  from  want,  and  in  those  who  have  a  he- 
reditary predisposition  to  or  a  taint  of  insanity,  is  a  confir- 
mation of  the  view  to  be  announced  that  the  physiological 
accidents  to  which  the  human  frame  is  liable  are  not  likely 
to  produce  insanity  unless  its  production  is  facilitated  by 
additional  causes. 

In  the  writer's  experience,  melancholia  is  more  likely  to 
ensue  during  the  period  of  lactation,  and  is  then  a  psycho- 
sis of  exhaustion,  while  mania  is  more  frequent  with  the 
puerperal  period  proper.  The  melancholia  due  to  excessive 
lactation,  or  late  weaning  of  the  child,  and  the  mania  of  the 
puerperal  state,  which  is  very  often  precipitated  by  sup- 
pression of  the  lochia  and  of  the  milk  secretion,  do  not  differ 
in  any  respect  from  ordinary  mania  and  melancholia. 
Hence,  the  writer  does  not  use  the  terms  puerperal  mania, 
or  melancholia  of  lactation,  but  mania  in puerpero  and  mel- 
ancholia ^.rAzr/^z//^,  to  show  that  no  clinical  but  only  an  eti- 
ological distinction  is  aimed  at  in  the  terms  employed. 
Sometimes,  especially  in  older  subjects,  and  when  there  has 
been  much  loss  of  blood,  dystocia,  or  some  emotional  de- 
pression, melancholia  instead  of  mania  develops  in  the 
puerperal  period.  In  short,  sthenic  states  favor  mania,  and 
asthenic  ones  melancholia  or  stupor. 

Occasionally,  transitory  frenzy  is  observed,  either  in  de- 

*  Die  Geistesstorungen  der  Schwangeren,  WOchnerinnen  und  SSngen- 
den. 


378  INSANITY. 

pendence  on  the  extreme  agony  of  child-birth,  or  as  a  man- 
ifestation of  the  delirium  of  the  parturient  state.  In  this 
condition,  infanticide,  or  suicide,  or  both,  are  sometimes 
committed.  The  view  has  been  expressed  that  when  albu- 
minuria co-exists  with  the  maniacal  and  frenzy-like  explo- 
sions of  the  puerperal  state,  the  uraemia  is  a  collateral  etio- 
logical factor.  No  substantial  grounds  exist  for  endorsing 
this  view,  and  the  writer  has  been  able  to  satisfy  himself 
of  the  absence  of  an  even  approximately  constant  relation 
of  renal  and  mental  disorder  in  the  puerperal  state. 

The  development  of  monomania  has  sometimes  been  ob- 
served to  date  from  a  confinement,  but  as  far  as  the  writer's 
experience  goes,  only  in  predisposed  subjects. 

The  relation  between  organic  disorders  of  the  male  geni- 
tal apparatus  and  insanity  is  far  less  constant  and  important 
than  that  existing  between  the  female  organs  and  mental 
disorder.  That  a  connection  between  the  development  of 
the  mind  and  the  male  genitals  exists,  is  indisputable. 
Even  if  we  assume  that  the  defective  development  of  the 
genital  system  found  in  brain  monstrosities,  idiots,  imbe- 
ciles, original  monomaniacs,  and  the  periodically  insane,  is 
an  accidental  accompaniment  of  the  neural  mal-develop- 
ment,  we  must  admit  the  convincing  fact  that  the  early 
extirpation  of  the  testicles,  as  in  eunuchs  and  castrated 
animals,  exerts  an  influence  on  the  mental  complexion  and 
development.  The  frequent  delusion  of  mysterious  inimi- 
cal influences  exerted  against  the  sexual  power,  of  sexual 
mutilation,  and  of  marital  infidelity,  so  characteristic  of 
alcoholic  insanity,  are  believed  by  Krafft-Ebing  to  have 
some  connection  with  the  fatty  degeneration  of  the  epithe- 
lia  in  the  seminal  tubuli  which  occurs  in  old  alcoholic  sub- 
jects. 

The  functional  abuse  of  the  male  sexual  apparatus  is  of 
more  general  importance  to  the  alienist  than  its  organic 
affections.  Excessive  venery  and  masturbation  have  from 
time  immemorial  been  supposed  to  be  the  direct  causes  of 
insanity.  Unquestionably  they  exert  a  deleterious  influence 
on  the  nervous  system,  and  may  provoke  insanity  partly 
through  their  direct  influence  on  the  nervous  centres,  partly 
through  their  weakening  effect  on  the  general  nutrition. 
That  there  is  a  close  connection  between  pathological  ner- 
vous states  and  the  sexual  function  is  exemplified  in  the 
satyriasis  of  mania  and  the  early  stages  of  paretic  dementia 
as  well  as   in  the  sexual  delusion  of  monomania  and    the 


THE    SOMATIC    ETIOLOGY    OF    INSANITY.  379 

abnormal  genital  sensations  of  that  condition.  In  the 
former  case  the  sexual  exaltation  is  a  result,  in  the  latter 
the  genital  sensations  are  collateral  phenomena  of  the 
psychosis,  but  there  are  certain  cases  in  which  while  an 
original  predisposition  may  have  existed,  masturbation  is 
the  factor  responsible  for  the  production  of  insanity. 
While  there  is  no  special  form  of  insanity  attributable  to 
masturbation,  yet  those  psychoses  due  to  or  accompanied 
and  modified  by  this  vice  seem  to  have  certain  characters 
in  common.  Melancholia,  stuporous  insanity,  katatonia, 
and  insanity  of  pubescence  are  the  forms  most  frequently 
found  in  masturbators,  and  the  essential  characters  of  these 
psychoses  are  always  recognizable  under  these  circum- 
stances. The  ordinary  characteristics  of  the  masturbator 
are,  however,  found  in  addition.  Thus  such  lunatics  are 
usually  retired,  sly,  suspicious,  hypochondriacal,  indolent, 
mean,  and  cowardl3^  They  are  capital  simulators,  and 
develop  an  art  in  concealing  and  in  practising  their  vice 
which  is  in  remarkable  contrast  with  their  stupidity,  apathy, 
and  feeble-mindedness  in  other  respects.  The  prognosis  of 
the  psychoses  associated  with  masturbation  in  males  is 
bad.*  A  variety  of  primary  deterioration  marked  by  moral 
perversion  is  observed  in  young  victims  of  the  habit,  which 
yields  to  treatment  if  the  habit  is  abolished.  If  unchecked 
it  culminates  in  complete  fatuity;  this  has  been  observed 
by  the  writer  in  subjects  between  the  eleventh  and  twenty- 
third  year,  and  is  one  of  the  numerous  conditions  which 
passes  under  the  designation  of  "primary  dementia  ;"  it  is 
the  only  one  to  which  the  term  insanity  of  masturbation 
can  be  properly  applied. f 

*  Genuine  melancholia,  usually  sine  delirio,  occurs  in  female  mas- 
turbators, and  has  a  very  good  prognosis,  probably  because  the  effects  of 
the  vice  are  far  less  severe  in  the  female  than  in  the  male  sex,  and  be- 
cause it  is  but  very  rarely  practised  with  persistency  and  for  long  periods 
by  the  former. 

f  Gloomy  as  the  prospect  of  the  confirmed  disorder  is  as  a  rule,  yet 
occasionally  very  unexpected  and  happy  terminations  are  seen.  Thus,  a 
young  man  of  bad  hereditary  antecedents,  who  for  days  had  not  quitted 
his  bed,  and  who  exhibited  feeble-mindedness  and  moral  perversion,  as  a 
result  of  this  habit,  was  about  to  be  sent  to  an  institution  by  the  writer. 
The  following  day,  he,  suspicious  as  these  subjects  are,  made  a  search 
and  found  the  commitment  papers.  After  perusing  them,  he  immediately 
turned  over  a  new  leaf,  went  into  his  father's  store,  did  the  best  he  could, 
abandoned  his  bad  habits,  and  to  this  day,  that  is,  during  a  period  of 
nearly  two  years,  has  filled  his  position  in  life  with  average  ability,  being 
remarkable  only  on  account  of  his  taciturnity. 


380  INSANITY. 

In  some  cases,  prolonged  and  excessive  masturbation  is 
observed  to  result  in  the  formation  of  a  neurotic  state, 
which  subsequently  serves  as  the  soil  for  the  development 
of  monomania,  characterized  by  hypochondriacal  or  re- 
ligious delusions.  In  the  female  sex  nymphomania  is 
observed  to  be  associated  with  a  similar  form  of  insanity; 
it  has  not  yet  been  determined  to  have  that  distinct  causal 
relation  to  monomania  which  masturbation  has  in  the 
male. 

The  view  held  by  Maudsley  and  others  that  sexual  ex- 
cesses are  the  all-important  factors  in  the  etiology  of  pa- 
retic dementia,  is  not  sustained  by  the  writer's  observations. 
Frequently  such  excesses  are  committed  by  paretic  de- 
ments in  the  earlier  exacerbations  of  their  malady,  as  well 
as  in  the  earlier  period  of  simple  mania;  but  while  they  un- 
doubtedly precipitate  the  progress  of  these  disorders,  they 
must  be  regarded  as  phenomena  and  not  as  causes. 

The  influence  of  neuralgia  and  pain  in  the  production  of 
insanity  is  limited  to  the  occasional  development  of  transi- 
tory delirium  or  frenzy,  analogous  to  that  observed  in  the 
puerperal  state.  Schuele  has  promulgated  an  utterly  fanci- 
ful view  as  to  the  existence  of  a  "  Dysthymia  neuralgica," 
under  which  head  this  author  believes  that  most  of  the 
psychoses  may  be  ranged.  It  is  safe  to  say  that  this  theory 
will  not  be  accepted  by  alienists  until  it  is  supported  by 
more  convincing  testimony  than  that  thus  far  adduced  in 
its  favor. 

While  a  vast  host  of  other  somatic  ills  might  be  enumer- 
ated, which  have  all  been  shown  to  have  an  influence  in  the 
production  of  mental  derangement,  yet,  multitudinous  as 
these  causes  are,  composing  as  they  do  a  twenty-fold  longer 
list  than  the  psychical  causes,  it  is  after  all  but  a  small 
percentage  of  the  insane  who  owe  their  trouble  to  their  in- 
fluence alone.  Blandford,*  with  approximate  accuracy  and 
little  elegance  of  diction,  says:  "  Men  and  women  become 
insane  because  it  is  their  nature  and  constitution  to  develop 
insanity,  and  when  we  hear  that  this  or  that  has  caused 
their  insanity,  it  is  often  their  restless  and  half-crazed  brain 
that  has  made  mountains  out  of  molehills,  and  given  an 
objective  existence  to  troubles  and  vexations  which  exist  in 
their  minds  subjectively,  and  have  no  outward  reality  what- 
ever."    It  is  true,  as  stated  in  this  extract,  as  also  at  the 


*  "  Insanity  and  its  Treatment,"  p.  153. 


THE   PSYCHICAL   CAUSES   OF  INSANITY.  381 

Opening  of  this  chapter,  that  the  inherited  and  acquired  in- 
sane constitution  is  the  fundamental  factor  in  most  cases  of 
insanit3\  This  conclusion,  and  the  assumptions  based  on 
it,  do  not,  however,  justify  us  in  ignoring  the  physical  dis- 
eases immediately  preceding  or  associated  with  insanity, 
for  there  is  more  satisfaction  to  the  practical  alienist  ni 
remedying  one  case  of  mental  disease  by  removing  its 
physical  cause,  than  in  diagnosticating  a  hereditary  predis- 
position in  ninety-nine  incurable  ones.  As  to  Blanciford's 
concluding  allegation  that  the  brain  of  the  insane  "  gives 
an  outward  existence  to  troubles  and  vexations  which  exist 
in  their  minds  subjectiveh%  and  have  no  reality  whatever," 
it  applies  to  the  fully  developed  disorder  and  not  to  the 
preincubatory  period  of  mental  derangement. 


CHAPTER   V. 

The  Psychical  Causes  of  Insanity. 

There  are  a  number  of  cases  on  record  in  which  a  sud- 
den emotion,  like  anger,  fright,  or  excessive  joy,  has  led  to 
the  immediate  development  of  insanity,  either  uncompli- 
cated or  associated  with  epilepsy.  Transitory  frenzy  has 
been  in  several  instances  noted  to  follow  angry  excite- 
ment, while  stuporous  insanity  and  katatonia  can  in  a 
comparatively  large  number  of  cases  be  traced  to  emotional 
shock  of  some  kind.  The  manner  in  which  these  causes 
operate  is  still  obscure.  Some  are  inclined  to  attribute  in- 
sanity resulting  from  them  to  the  vaso-motor  disturbance 
induced  by  emotional  episodes.  The  writer  believes  that 
in  the  case  of  stuporous  insanity  the  production  of  the 
functional  suspension  of  all  the  mental  faculties  is  com- 
parable to  that  anaesthesia  of  the  retina  which  results  after 
sudden  exposure  to  a  very  dazzling  light.  An  external 
impression  if  it  exceeds  the  physiological  receiving  power 
of  a  nerve  centre,  provokes  a  functional  blunting  of  that 
centre  for  impressions  of  lesser  intensity,  and  this  applies 
to  emotional  influences  as  well  as  to  more  coarsely  material 
ones. 

Ordinarily  the  psychical  causes  of  insanity  do  not  act  in 
as  direct  a  manner  as  in  the  case  just  cited.      It  is   usually 


382  INSANITY. 

only  after  a  succession  of  assaults  continued  through  a 
number  of  years  that  the  mental  organ  breaks  down. 
Worry  and  disappointment,  hopes  long  deferred,  and  the 
attendant  conflicts  of  the  inner  man,  the  continued  result- 
ing over- strain  of  an  organ  whose  physiological  state  is  one 
of  equilibrium,  constitute  already  a  pathological  state,  a 
functional  abuse  of  the  brain.  The  intimate  relation 
between  the  mind  and  the  body  is  shown  by  the  somatic 
disturbances  which  ensue.  A  not  improperly  so-called 
nervous  dyspepsia,  constipation,  and  functional  disturbance 
of  the  heart  and  kidneys  are  common  sequelae  of  prolonged 
emotional  over-strain,  and  all  of  them  react  on  the  organ 
whose  functional  disturbance  is  in  the  first  place  respon- 
sible for  their  existence.  Headache,  sleeplessness,  7naiaise, 
a  tendency  to  empty  speculation  either  in  the  way  of  hypo- 
chondriasis, suspicion  of  others,  or  distrust  of  self,  so  com- 
mon features  of  the  prodromal  period  of  insanity,  mark 
this  reaction,  and  are  in  part  due  to  the  continuance  of  the 
original  emotional  causes,  and  in  part  to  the  somatic  state 
they  have  provoked. 

This  preliminary  period  of  insanity,  as  it  may  not  im- 
properly be  termed,  may  last  for  years  without  leading  to 
serious  developments,  and  it  undoubtedly  disappears  or 
becomes  latent,  with  or  without  treatment,  in  a  far  larger 
number  of  patients  than  those  who  become  actually  insane. 
It  is  those  who  have  an  hereditar)'^  predisposition,  or  who 
resort  to  stimulants  and  narcotics,  lending  a  spurious  vigor 
to  the  exhausted  nervous  apparatus,  who  furnish  the  largest 
contingent  to  our  insane  population.  In  case  there  is  an 
hereditary  predisposition,  monomania,  periodical  mania,  or 
melancholia  are  likely  to  develop.  In  case  alcoholic  or  sexual 
excesses  are  superadded,  paralytic  dementia  may  result. 
In  uncomplicated  cases  the  insane  explosion  is  usually  in 
the  form  of  a  mania  or  melancholia,  the  development  of 
one  or  the  other  being  probably  dependent  on  the  constitu- 
tional tendency  of  the  patient,  whether  this  be  in  the  direc- 
tion of  sthenic  or  asthenic  reaction  to  pathological  causes. 

Intellectual  labor  is  but  very  rarely  a  factor  in  the 
causation  of  insanity.  It  is  only  where  the  mental  or- 
gan is  weakened  by  physical  disease  and  thrown  off  its 
equipoise  by  emotional  crises,  that  mental  labor  exerts  an 
injurious  influence.  If  persisted  in  under  these  circum- 
stances, primary  deterioration  is  likeh^  to  appear. 

Aside  from  this  case,  mental  labor  of  a  proper  kind  is,  so 


THE   PSYCHICAL   CAUSES   OF  INSANITY.  383 

far  from  being  a  cause  of  insanity,  one  of  the  most  efficient 
prophylactics  against  mental  disorder.  More  than  one 
member  of  an  insane  family  has  been  prevented  from  join- 
ing his  relations  in  the  asylum  by  some  fortunate  accident 
which  threw  a  routine  occupation  in  his  way.  It  is  with  the 
mind  as  well  as  with  the  body,  a  proper  degree  of  exercise 
is  essential  to  its  health,  and  philosophers  and  scientists 
who  have  been  free  from  worry  and  vexation,  and  have 
pursued  the  even  tenor  of  investigation  and  reasoning, 
have  been  and  are  noted  for  reaching  advanced  years  with- 
out manifesting  any  mental  decay,  or  much  less  than  other 
persons  at  the  same  period  of  life.  Humboldt,  Darwin, 
Cuvier,  not  to  mention  a  host  of  others,  are  examples  of 
this  fact.  On  the  other  hand,  poets,  musicians,  and  artists 
rarely  reach  advanced  years  without  manifesting  deterio- 
ration, and  contribute  not  a  little  to  the  insane  population, 
if,  indeed,  many  do  not  join  the  ranks  of  these  professions 
because  they  have  a  taint  of  that  insanity  which  is  supposed 
to  be  allied  to  genius  in  them.  While  the  greatest  poets  and 
artists  have  been  persons  of  the  highest  mental  integrity,  it 
is  best  to  discourage  persons  who  have  a  predisposition  to 
insanity  from  cultivating  the  higher  arts.  Lenau,  Holder- 
lin,  Cowper,  Byron,  Poe,  and  a  number  of  others,  are  illustra- 
tions of  the  association  of  this  tendency  with  the  hereditary 
taint,  and,  in  part,  of  its  unfavorable  influence.  Our  daily 
experience  shows  that  even  in  the  cultivation  of  the 
mechanical  arts,  and  of  the  strictly  scientific  branches,  there 
is  room  enough  for  the  play  of  insane  project-making  and 
delusions.  Dilettantic  aspiration  is  the  foe  of  the  insanely 
disposed  in  every  branch  of  the  arts  and  sciences;  the  insane 
inventors,  political,  socialistic,  and  scientific  would-be  re- 
formers crowding  the  quiet  wards  of  some  institutions 
strikingly  demonstrate  this. 

The  influence  of  mental  and  emotional  over-strain  in  the 
production  of  mental  derangement  of  certain  types,  has 
been  discussed  in  Part  Second  (Chapters  XI  and  XV).  It 
remains  for  us  to  refer  to  the  influence  of  education  on  the 
development  of  the  mind  in  its  relations  to  insanity.  The 
earlier  an  injury  affects  the  nervous  centres  the  more  pro- 
found are  its  results.  This  is  illustrated,  as  to  organic 
affections,  by  such  examples  as  the  porencephaly  of  Heschl. 
When  this  lesion  involves  the  brain  of  a  child,  imbecility 
results,  but  when  it  is  produced  in  the  brain  of  the  adult, 
the  mind  may  remain  unaffected.     It  is  the  same   with  the 


384  INSANITY. 

functional  abuse  of  the  organ.  The  earlier  emotional  over- 
strain, harsh  treatment,  sensational  reading,  and  ambitious 
rivalry  occur  in  the  history  of  mental  development,  the 
more  likely  are  they  to  awaken  the  slumbering  predisposi- 
tion to  insanity  where  it  exists,  or  to  develop  it  where  it 
does  not  exist.  The  most  important  task  of  the  alienist  of 
the  future  will  be  a  thorough  revision  of  our  educational 
methods.  There  can  be  little  doubt  that  competitive  ex- 
aminations, mechanical  grinding  of  the  "spelling  match" 
variety  and  the  "  Gradgrind  "  principle  will  be  among  the 
things  that  were,  after  that  revision  is  made. 


CHAPTER  VI. 

The  Medicinal  and  Dietetic   Treatment  of  Insanity. 

It  may  be  accepted  as  a  dogma  of  psychiatry  that  the 
leading  morbid  phenomena  constituting  insanitj'  can  be 
influenced  by  drugs  in  only  very  exceptional  instances.  As 
a  rule,  drugs  act,  when  they  act  at  all,  indirectly,  although 
a  few  of  them  seem  to  influence  the  fundamental  patho- 
logical state  of  alienation,  especially  when  located  in  the 
vaso-motor  system,  most  happily. 

Among  the  general  objects  of  medicinal  and  dietetic 
treatment  are  the  improvement  of  the  general  nutrition 
and  the  remedying  of  insomnia.  The  chief  field  for  this 
branch  of  therapeutics  is  consequently  among  the  acute 
forms  of  derangement. 

In  disorders  of  the  sthenic  type  like  mania,  when  the 
chest  organs  are  in  a  sound  condition  and  the  general  nu- 
trition is  goodj  the  medicinal  treatment  is  mainly  limited 
to  the  control  of  motor  excitement  and  the  relief  of  insom- 
nia. The  best,  most  reliable,  and  safest  drug  for  the  former 
purpose  is  comum,  the  only  reliable  preparation  obtainable 
being  Squibb's  fluid  extract.*  As  a  rule,  twenty  minims  will 
suffice  as  a  first  dose,  while  from  ten  to  fifteen  minims  may 
be  subsequently  given  every  half  hour  or  hour  until  the 
excitement  is  subdued.     In  patients  whose  tolerance  of  the 


*  It  is  necessary  to  test  every  new  sample,  as  the  strength  of   the 
preparation  varies. 


THE   MEDICINAL   TREATMENT   OF   INSANITY.       385 

drug  has  been  tested,  much  larger  doses  may  be  safely  ad- 
ministered. In  one  case  the  writer  has  known  death  to 
ensue  in  a  debilitated  patient  who  took  a  drachm  of  the 
drug,  through  the  negligence  of  an  attendant,  while  the 
same  dose  was  repeatedly  found  to  fall  within  the  physio- 
logical limits  in  its  effects  in  others.  The  physiological 
action  of  conium  is  still  the  subject  of  discussion.  The 
writer,  from  his  observations,  is  inclined  to  believe  with 
Harley,  Davidson,  and  Dyce  Brown  that  it  acts  on  the  cere- 
bral centres,  and  not  alone  on  the  peripheral  nerves  as  Kol- 
liker  and  Guttmann  claim.  In  maniacal  patients  it  is  truly 
remarkable  to  find  how  rapidly  with  the  progressing  aboli- 
tion of  muscular  overaction  the  mental  processes  become 
clearer  and  the  flight  of  ideas  less  rapid  just  prior  to  the 
patient's  dropping  off  into  what  usually  proves  to  be  a  re- 
freshing slumber.  No  drug  in  the  whole  range  of  those 
used  in  insanity  is  so  certain  in  its  action  and  leaves  so  few 
ill  effects  behind  as  conium.  Patients  who  stagger  around 
under  its  influence,  and  are  compelled  to  take  to  their  beds 
and  become  tranquil  in  consequence,  awake  some  hours 
thereafter  in  a  condition  of  comparative  improvement.  It 
is  advisable  not  to  push  the  drug  after  the  first  indications 
of  motor  relaxation  are  observed,  but  to  watch  it  most  care- 
fully then. 

A  combination  of  equal  parts  of  bromide  of  potassium 
and  chloral*  is  the  best  medicinal  remedy  for  the  insomnia 
of  maniacal  patients.  The  necessary  dosage  varies  so 
greatly  that  it  is  impossible  to  prescribe  any  rule.  With  a 
patient  of  good  physique,  and  whose  organs  are  in  a  sound 
condition,  it  will  be  simply  useless  to  give  the  amounts 
ordinarily  given  for  insomnia  in  private  practice  ;  the 
double,  nay  the  treble,  must  be  given;  and  better  to  pro- 
duce one  good  night's  or  half  night's  rest  with  a  single 
large  dose  than  to  fail  repeatedly  with  a  succession  of  small 
doses,  whose  aggregate  amount  and  whose  permanently 
injurious  influence  is  much  greater,  while  they  fail  to  pro- 
duce the  good  effect  of  a  single  large  one.  Neither  of 
these  drugs  should  be  used  night  after  night,  except  in 
emergencies  or  in  epileptic  insanity,  for  it  is  not  so  much 
the  object  of  the  alienist  to  crowd  down  a  psychosis  as  to 
establish  a  series  of  relatively  lucid  periods,  and  thus  to  tip 

*  Not  of  two  or  three  parts  of  the  former  and  one  of  the  latter,  as  is 
frequently  recommended. 


386  INSANITY. 

the  scale  sufficiently  on  the  side  of  struggling  nature  to 
overcome  the  pathological  influence.  He  should  bear  in 
mind  that  mania  disappears,  not  suddenly,  as  a  rule,  but  by 
a  series  of  oscillations  between  the  healthy  and  the  diseased 
state,  which  finally  merge  into  a  healthy  equilibrium,  and 
that  in  the  absence  of  a  specific  remedy  it  is  wisest  to  fol- 
low physiological  lines  of  treatment.  No  mania  was  ever 
choked  down,  but,  at  most,  prolonged  or  diverted  into  the 
channel  of  deterioration  by  the  excessive  use  of  hypnotic 
and  calmative  drugs.  It  is  even  desirable  to  permit  a  ma- 
niacal patient  to  remain  excited  at  some  periods  and  within 
certain  limits,  as  only  under  these  circumstances  can  that  men- 
tal influence  which  is  often  more  important  than  the  drug  be 
tested  and  exerted  so  as  to  permanently  benefit  the  patient. 
In  paretic  dementia  it  should  be  particularly  carefully 
watched,  and  in  the  later  stages  of  that  affection  is  al- 
together contraindicated,  owing  to  the  fact  that  it  may  in- 
tensify the  angio-paralytic  phenomena  of  that  disease,  or 
produce  cardiac  paralysis  directly. 

Among  the  procedures  which  are  recommended  for  the 
treatment  of  sthenic  delirious  conditions,  and  of  such  which, 
like  diiirium  grave,  are  associated  with  incipient  and  acutely 
inflammatory  states,  venesection  at  the  mastoid  process, 
the  use  of  ice-bags,  the  cold  pack,  baths,  and  of  hydragogue 
cathartics  are  the  most  efficient.  \'enesection  is  very  rarely 
applicable,  because  the  period  when  it  might  be  useful  is 
usually  past  when  the  patient  comes  under  the  alienist's 
cognizance;  its  use  should  be  limited  to  cases  of  suppressed 
menstruation  and  grave  delirium.  In  insanity  with  excite- 
ment we  have  usually  to  deal  with  a  condition  rather  of 
undernutrition  than  of  over-nutrition,  and  it  is  in  obedience 
to  a  rational  meditation  on  this  fact  that  phlebotomy  and 
the  leech  are  almost  banished  from  asylums  for  the  insane.* 

The  use  of  baths,  originally  recommended  by  de  Bois- 
mont  in  recent  cases  of  mania  and  melancholia  with  ex- 
citement, is  most  beneficial.    Baths  of  nearly  the  temperature 

*  The  leading  expert  for  the  prosecution  in  the  Guiteau  trial,  who  had 
up  to  that  time  enjoyed  a  well-deserved  reputation  as  a  gynaecologist, 
evidently  stimulated  by  his  forensic  achievements  as  an  alienist  expert 
on  the  occasion  referred  to,  applied  venesection  to  a  case  of  melancho- 
lia (!),  and  reported  an  almost  instantaneous  recovery.  The  case  was  cer- 
tainly one  illustrating  the  influence  of  mental  impressions,  and  signifi- 
cantly demonstrates  that  it  was  simply  an  instance  of  hysteria.  Vene- 
section in  true  melancholia  would  be  as  justifiable  as  venesection  in  post- 
partum hemorrhage. 


THE   MEDICINAL   TREATMENT   OF   INSANITY.       387 

of  the  body,  and  which  may,  in  well-nourished  maniacs,  be 
prolonged  for  twelve  hours  and  over,  exert  an  excellent 
calmative  and  sometimes  a  better  soporific  effect  than  the 
medicinal  calmatives.  The  cold  pack  is  also  useful  in  mania 
and  agitated  melancholia  in  a  double  way:  first,  because  of  its 
effect  on  the  vaso-motor  system;  and  second,  because  of  its 
effect  on  the  metabolic  processes,  and  consequent  curative 
effect  on  anaemia,  if  present.  Neither  the  bath  nor  the  cold 
pack  should  be  used  in  patients  whose  temperature  is  below 
98°,  and  on  the  whole  they  are  less  frequently  applicable  in 
melancholias  than  in  manias.  It  will  be  found  an  excellent 
plan  to  alternate  in  the  use  of  narcotic  and  hydro-therapeutic 
calmatives,  in  order  to  prevent  the  patient  from  becoming 
accustomed  to  the  influence  of  either. 

In  conditions  like  the  exacerbations  of  paretic  dementia, 
of  which  vaso-motor  paralysis  is  a  feature,  ergot  is  very 
useful.  The  elaborate  researches  of  Kiernan,  undertaken 
with  this  drug  at  the  suggestion  of  the  writer,  prove  that  it 
has  a  marked  influence  both  on  the  status-like  epileptiform 
and  on  the  maniacal  seizures  of  this  disease.  Amyl-nitrite 
is  indicated  in  the  opposite  condition;*  and  as  this  drug, 
which  on  account  of  its  evanescent  action  must  be  repeatedly 
given,  effectually  remedies  vaso-motor  spasm,  it  is  of  great 
service  and  sometimes  directly  curative  in  stuporous  in- 
sanity and  melancholia,  particularly  of  that  kind  in  which 
the  "frozen  attitude"  occurs.  Quite  magical  effects  have 
been  seen  by  the  writer  in  cases  of  katatonia.  In  the  first 
patient  selected  for  trial,  who  was  in  the  cataleptic  phase, 
complete  lucidity  occurred  immediately  after  the  first  in- 
halation; the  cataleptic  state  recurred  in  an  hour,  and  as 
quickly  yielded;  and  the  persistent  use  of  the  drug  ma- 
terially hastened  the  patient's  ultimate  recovery.  In  apa- 
thetic stuporous  and  cataleptic  patients  it  is  necessary  to 
resort  to  the  device  of  closing  their  nostrils  and  mouth  for 
a  few  moments  before  presenting  the  amyl-nitrite  to  be  in- 
haled, in  order  to  compel  the  patient  to  take  a  deep  breath. 
One  or  two  deep  inspirations  mediate  a  more  thorough 
action  of  the  drug  than  twenty  superficial  ones,  and  it  is 
for  the  reason  that  they  neglect  this  precaution  that  physi- 

*  The  writer  is  aware  that  this  drug  is  recommended  by  some  English 
writers  for  the  epileptiform  seizures  of  paretic  dementia.  Although  its 
use  is  sometimes  followed  by  a  cessation  of  the  fit,  it  is  difficult  to  see 
how,  in  view  of  the  angio-paralytic  action  of  the  drug,  any  other  but  a 
deleterious  influence  can  be  exercised  by  it  in  this  condition. 


388  INSANITY. 

cians  so  frequently  fail  in  its  use.  The  patient's  face  must 
flush  and  his  pulse  become  full  and  expansive,  or  the  drug 
has  not  been  properly  given.  Happily,  the  very  conditions 
in  which  it  is  of  service  are  the  ones  in  which  the  greatest 
tolerance  is  shown  to  it.  Only  in  elderly  subjects  and  those 
having  arterial  disease  should  its  use  be  proscribed. 

Opium  is  the  most  generally  useful  of  all  drugs  in  in- 
sanity. It  has  a  direct  influence  on  the  mind,  antithetical 
to  the  painful  emotional  state  of  melancholia  and  to  the 
persecutory  delirium  of  monomania.  While  it  is  itself  a 
vascular  stimulant,  yet  its  influence  on  the  heart  is  such  as 
to  overcome  the  wiry  pulse  of  extreme  melancholia  and 
other  conditions  in  which  the  blood  current  in  the  brain  may 
be  assumed  to  be  diminished.  It  is  because  of  the  peculiar 
union  of  a  vaso-constrictor  influence  with  its  well-known 
effect  on  the  heart,  that  it  of  all  generally  stimulating  nar- 
cotics is  applicable  to  paretic  dementia,  and  that  we  have 
the,  to  a  superficial  view,  paradoxical  fact,  that  Avhile  opium 
and  morphia  are  counterindicated  in  manial  furor,  they  are 
strongly  indicated  in  the  furious  exacerbations  as  also  in 
the  quiet  intervals  of  paretic  dementia.  Morphia  is  of  ex- 
cellent service  in  the  treatment  of  periodical  insanity  whose 
exacerbations  it  may  entirely  check.  As  a  rule  it  is  best 
to  give  opium  and  its  preparations  by  the  mouth,  for  pa- 
tients with  persecutor}'  or  hypochondriacal  ideas  are  very 
apt  to  interpret  a  hypodermic  injection  as  an  assault,  an 
impregnation  with  poison  or  in  some  other  delusional  wa}', 
and  it  is  a  daily  experience  with  the  insane  that  the  start- 
ing of  a  suspicion  or  a  new  train  of  delusions  will  undo  the 
best  therapeutical  measures.  Whether  it  is  for  this  reason 
or  some  other,  opium  does  not  act  well  in  passive  melan- 
cholia. The  deodorized  tincture  of  opium  and  the  bimeco- 
nate  of  morphia  are  the  best  preparations,  and  while  opium 
produces  constipation,  and  it  is  necessary  to  give  a  gentle 
cathartic  with  it  at  first,  yet  when  its  prolonged  use  is  neces- 
sary it  will  be  found  that  the  intestinal  canal  soon  resumes 
its  functions,  or  at  the  worst  that  these  can  be  readily 
regulated.  In  the  maniacal  periods  of  paretic  dementia 
very  large  doses  are  borne.  In  melancholia  and  anxious 
states  generally  it  is  best  to  begin  with  twenty  minims,  and 
continue  giving  from  ten  to  fifteen  minims  every  two  hours, 
till  an  effect  on  the  pupil  and  pulse  is  obtained. 

In  nearly  all  the  conditions  in  which  opium  is  admissible 
digitalis  or  convallaria  can  be  advantageously  given.     It 


THE   MEDICINAL   TREATMENT   OF   INSANITY.       389 

may  be  accepted  as  a  rule  in  insanity  that  the  administra- 
tion of  both  these  drugs  should  be  guided  by  the  condition 
of  the  heart.  Opium  should  not  be  given,  or  at  least  not 
given  without  digitalis  or  convallaria,  in  cases  where  serious 
valvular  lesion  and  dilatation  exist,  and  digitalis  should  not 
be  given  when  there  is  high  arterial  pressure,  nor  in  one 
condition  which  is  very  rare  in  the  asylum  ward — cardiac 
hypertrophy. 

The  most  recent  fashion  in  psychiatrical  therapeutics  is 
the  use  of  hyoscyamia.  The  large  doses  of  this  drug  rec- 
ommended by  the  English,  and  the  still  larger  ones,  em- 
ployed by  a  few  American  physicians,  are  calculated  to 
stagger  one.  Schiile  expresses  a  natural  surprise  at  the  in- 
discriminate abuse  of  this  drug,  and  sounds  a  well-timed 
warning  as  to  the  toxic  effects,  such  as  aphonia  and  ataxia, 
occasionally  observed  to  follow  very  small  doses  of  hyoscya- 
mia. Until  a  more  careful  study  of  its  effects  shall  have 
been  made,  the  writer  would  hesitate  to  recommend  it,  as 
long  as  we  have  so  many  tried  reliable  and  safer  remedies 
at  our  disposal.  The  tincture  of  hyoscyamus  has  been  long 
given  by  Kiernan  in  combination  with  chloral  hydrate  and 
bromide  of  sodium  as  a  calmative  of  excited  patients;  and 
the  writer  is  unaware  of  any  good  effects  obtained  from 
hyoscyamia  which  are  not  obtainable  from  this  much  safer 
combination  or  from  that  with  conium. 

Billod  claims  to  have  obtained  excellent  remedial  effects 
in  the  treatment  of  hallucinatory  conditions  by  means  of 
stramonium.  The  writer  has  no  experience  with  this  drug, 
but  its  advocate's  position  entitles  the  drug  to  a  more  ex- 
tensive trial  than  it  has  thus  far  received. 

Cannabis  indica,  in  large  doses  given  at  intervals  of  two 
or  three  days,  sometimes  has  an  excellent  effect  on  de- 
pressed states,  and  its  influence  in  some  cases  is  rapid  and 
strikingly  manifest.  In  a  case  of  folie  du  doiite  its  influence 
seemed  to  mark  the  turning  point  in  the  favorably  termi- 
nating history  of  the  case.  Unfortunately  the  unreliability 
of  the  preparations  obtainable  in  America  is  a  bar  to  its 
use,  and  even  the  English  extracts  so  highly  praised  on 
both  sides  of  the  Atlantic  are  often  inert. 

Strychnia  is  one  of  those  drugs  which,  while  they  exert 
no  specific  influence  on  any  special  morbid  factor  of  insan- 
ity, rank  high  as  general  tonics  in  this  disorder.  Its  excel- 
lent influence  on  the  tone,  both  of  the  voluntary  and  involun- 
tary muscles,  is  shown  in  all  conditions  of  motor  anenergy, 


390  INSANITY. 

and  visceral  torpor;  hence  its  use  is  to  be  recommended  in 
melancholia,  stuporous  insanitj'  and  other  states  of  neural 
depression,  as  well  as  in  all  conditions  in  which  the  sphinc- 
ters are  relaxed.  It  has  also  a  favorable  effect  on  states  of 
vaso-motor  paresis,  such  as  paretic  dementia  and  the  later 
periods  of  grave  delirium;  it  is  hence  indicated  wherever 
ergot,  with  which  it  may  be  advantageously  combined,  is 
applicable.  In  conditions  with  high  vascular  tension  its  use- 
fulness is  problematical,  and  in  melancholia  with  the  "  frozen 
attitude"  which  is  associated  with  a  spasmodic  state  of  the 
entire  muscular  system,  and  regarding  the  influence  of 
strychnine  on  which  the  writer  has  no  observations  at  his  dis- 
posal, it  will  be  well  to  employ  it  very  carefully.  It  would  be 
hasty,  however,  to  assume  that  a  spasmodic  state  due  to  a 
mechanism  altogether  the  opposite  of  a  central  state  of  func- 
tional over-activity  must  necessarily  be  influenced  unfavora- 
bly by  a  drug  which  produces  spasm  through  such  a  mechan- 
ism. Strychnia  is  the  most  general  neural  stimulant  at  our 
disposal;  its  tonic  influence  is  exerted  on  the  entire  central 
nervous  apparatus,  and  is  not  at  all  chiefly  localized  in  the 
cord,  as  some  have  believed.*  It  stimulates  the  central  and 
peripheral  sensory  and  the  central  motor  and  the  vaso- 
motor systems,  and  directly  affects  the  cerebral  functions 
in  a  favorable  way.  Nowhere  is  this  better  manifest  than 
in  paretic  dementia.  The  effect  of  strychnia  is  somewhat 
lessened  by  a  prolonged  administration;  in  addition,  while 
the  appetite  is  at  first  very  happily  influenced  by  it,  it  is 
afterwards  unfavorably  affected;  for  all  these  reasons,  it  is 
best  to  give  nux  vomica  and  strychnia  on  an  "  interrupted 
plan."  The  drug  should  not  be  suddenly  administered  in 
large  doses,  but  in  rising  ones,  till  the  desired  physiologi- 
cal effects  are  obtained;  then  they  should  be  gradually  de- 
creased, each  cycle  of  administration  lasting  about  ten,  with 
intervals  of  five  days. 

As  a  general  rule,  the  combination  of  several  drugs  in  a 
mixture,  intended  to  be  constantly  used  even  in  the  treat- 
ment of  one  and  the  same  patient,  is  to  be  deprecated. 
Under  these  circumstances  it  is  impossible  to  regulate  the 
administration  of   remedies  which,  like  those   used  to  quiet 

*  The  writer  in  the  course  of  a  large  number  of  experiments  performed 
on  animals  of  all  classes  ("  The  Anatomical  and  Physiological  Efifects  of 
Str^'chnia,  on  the  Brain,  Spinal  Cord,  and  Nerves;"  Prize  Essay  of  the 
American  Neurological  Association)  found  that  the  characteristic  spasms 
of  strychnia  poisoning  are  in  part  at  least  of  a  cerebral  origin. 


THE   MEDICINAL   TREATMENT   OF   INSANITY.       39! 

insane  excitement,  must  more  or  less  closely  approach  in 
their  effects  the  boundary  between  life  and  death.  To  com- 
plicate the  sufficiently  difficult  .task  of  approaching  this 
limit  sufficiently  near  to  obtain  the  useful  effects  of  a  drug 
on  the  one  hand,  and  not  to  pass  beyond  it  on  the  other, 
by  combining  it  with  remedies  which  may  or  may  not  mask 
or  neutralize  its  effects,  is  exceedingly  unwise.  What  is- 
useful  in  the  way  of  combination  in  psychiatry  has  been; 
tested  in  general  practice,  as  for  example  the  uniting  witb 
opium  of  a  slight  amount  of  belladonna.  As  to  the  harmo- 
nious combination  of  chloral  hydrate  and  bromide  of  so- 
dium,* the  general  caution  must  be  made,  that  the  nearer 
the  patient  approaches  confusion  or  moria,  the  less  bromide 
must  be  given  to  him;  and  in  such  cases  it  may  be  well  to 
give  the  chloral  alone.  Unless  there  is  an  emergency  de- 
manding the  instant  calming  of  a  boisterous  or  destruc- 
tively maniacal  patient,  it  is  best  to  regulate  the  functions 
of  the  gastro-enteric  tract  before  proceeding  to  administer 
any  drugs,  and  when  administering  them  to  bear  their  pos- 
sible influence  on  the  digestion  continually  in  mind,  and  to 
regulate  their  administration  accordingly.  In  the  majority 
of  cases,  the  neurotic  medicines  are  better  absorbed  and 
better  borne  in  an  alkalinized  stomach  than  in  one  contain- 
ing either  an  acid  gastric  juice  or  the  acid  products  of  fer- 
mentation found  in  some  forms  of  gastritis.  This  is  par- 
ticularly the  case  with  chloral  hydrate  and  the  bromides. 
Both  the  hypnotic  purpose  and  the  "gastric"  indications 
are  met  better  if  a  glass  of  hot  milk  is  given  immediately 
after  the  chloral  and  before  retiring. 

Alcoholic  stimulants  are  of  great  service  in  all  states  of 
depression  and  restlessness,  excluding  those  of  a  maniacal 
character.  Their  use  is  therefore  contraindicated  in  the 
active  phases  of  paretic  dementia,  and  they  should  be  spar- 
ingly used,  if  at  all,  in  the  quiet  intervals  and  remissions  of 
that  disorder.  They  should  never  be  given  in  periodical 
lunatics,  without  bearing  the  danger  of  the  formation  of  a 
dipsomaniac  tendency  by  them  in  mind.  Malt  liquors  in 
moderate  quantities,  not  exceeding,  say,  a  half  a  pint  of  beer, 
ale,  or  porter  daily,  will  be  found  useful  both  as  nutrients 
and  as  calmatives  in  badly  nourished  subjects,  suffering 
from  insomnia.     They  should  not  be  administered  unless 

*  Which  takes  the  place  of  bromide  of  potassium  in  every  respect,  and 
disturbs  the  stomach  less. 


392  INSANITY. 

the  patients  have  out-door  exercise  at  the  same  time,  and 
the  slightest  sign  of  gastric  catarrh  is  a  contraindication  to 
their  use. 

Phosphorus  has  been  recommended  on  theoretical 
grounds  in  all  forms  of  insanity.  The  belief  in  its  virtues 
was  of  course  strongest  in  those  days  when  it  was  believed 
that  the  "  phosphates"  are  continually  drained  from  the 
brain  through  the  urine,  and  that  the  chief  functional  sub- 
stance in  the  brain  is  a  phosphorized  oil  or  fat.  But  the 
dictum  that  "  without  phosphorus  no  thought,"  correct  as  it 
is,  does  not  lead  to  the  conclusion  that  phosphorus  is  to 
the  brain  in  insanity  what  iron  is  to  the  blood  in  anaemia, 
as  if  delusions,  hallucinations,  abulia,  and  amnesia  were 
comparable  to  strikes  in  a  match  factory.  Undoubtedly 
the  restorative  nutrition  of  the  brain  is  an  important  task 
for  the  psychiatrist,  but  he  may  crowd  phosphorus  into  the 
stomach,  without  materially  influencing  abnormal  mental 
processes.  It  is  true  that  the  symptoms  of  mania  and 
melancholia  are  probably  the  expressions  of  disturbed 
biochemical  states  of  the  brain  tissue,  but  we  are  not  able 
to  put  our  finger  on  any  one  component  element,  and  say 
that  this  one  is  too  rapidly  wasted,  and  that  one  not  rapidly 
enough  removed.  Even  if  we  could  do  so,  we  might  be  power- 
less to  control  the  vaso-motor  disturbance  so  intimately 
connected  with  the  biochemical  anomalies.  As  it  is,  the 
chemistry  of  the  brain  has  taught  us  nothing  regarding 
the  particular  role  which  phosphorus,  in  the  combination 
of  a  distearyl-glycerin-phosphoric  acid  combined  with 
neurin  as  a  base,  plays  in  acute  insanity.  We  are  limited 
in  our  indications  to  empirical  observations,  and  these 
teach  us  that  in  the  deteriorating  mental  states,  as  well  as 
in  those  associated  with  general  nervous  exhaustion,  phos- 
phorus is  of  considerable  benefit.  The  problem  of  furnish- 
ing a  reliable  and  easily  assimilable  preparation  of  phos- 
phorus has  not  been  satisfactorily  solved.  The  trade-mark 
preparations  are  some  of  them  very  well  borne  by  the 
stomach,  but  inconstant  in  strength,  and,  in  two  prominent 
instances  at  least,  not  honestly  kept  up  to  their  original 
standard. 

Iron  is  indicated  in  that  large  class  of  the  insane  in 
whom  anaemia  is  present.  No  other  rules  are  required 
for  guidance  in  its  administration,  or  for  the  administra- 
tion of  other  restorative  remedies,  than  those  followed 
in  general  practice. 


THE   MEDICINAL   TREATMENT   OF   INSANITY.       393 

Quite  extravagant  hopes  have  been  based  on  the  alleged 
curative  effect  of  electricity  in  insanity.  Superficial  theor- 
izers  have  even  undertaken  to  indicate  the  special  kinds  of 
current,  and  directions  of  such,  to  be  applied  to  the  head  in 
various  forms  of  insanity,  and  it  is  to  be  presumed  that  the 
more  modern  imposition  of  static  electricity  will  come  into 
vogue,  and  after  a  brief  sway  over  the  minds  of  the  credu- 
lous, and  an  occasional  success  with  a  simulating  or  hys- 
terical patient,  share  the  fate  of  other  epidemics  of  char- 
latanism. Electricity  can  have  from  the  very  nature  of  the 
case  no  specific  effect  on  insanity.*  Its  applicability  is 
limited  to  those  forms  in  which  there  is  simple  atony,  as  in 
stuporous  insanity,  and  to  those  which  are  associated  with 
organic  and  functional  disease  of  the  nervous  axis;  in  the 
latter  case  the  ordinary  rules  of  electro-therapy  apply.  In 
stuporous  insanity  its  effect  is  to  stir  up  the  patient;  but  we 
should  be  very  sure  of  our  diagnosis  before  applying  it, 
and  not  confound  atonic  melancholia  with  stuporous  in- 
sanity, for  in  a  melancholic  patient  electrical  manipula- 
tions would  probably  provoke  additional  delusions  of  per- 
secution to  those  he  already  entertains. 

If  we  were  acquainted  with  the  molecular  condition  of 
the  brain  in  health  and  disease,  and  if  we  understood  better 
the  exact  influence  of  electricity  on  the  molecular  and 
dynamic  states  of  that  organ,  we  would  be  better  able  than 
we  now  are  to  formulate  the  indications  for  the  use  of  this 
potent  neurotic  agent. 

The  diet  of  insane  patients  should  be  nutritious  and 
easily  assimilable.  In  view  of  the  frequent  coexistence  of 
gastro-intestinal  disturbance,  milk  and  raw  meat  f  should 

*  Unless  we  are  to  assume  the  correctness  of  such  dicta  as  the  one  con- 
tained in  the  following  citation  from  the  testimony  of  the  prosecuting 
witnesses  in  the  Guiteau  trial  (p.  1363,  Dr.  H.  P.  Stearns  testifying): 
Question.  What  is  your  theory  of  a  person  becoming  suddenly  insane 
through  the  excitement  of  fear  in  its  operation  on  the  brain  ?  Answer. 
I  suppose  that  to  be  injury  of  the  tissue  of  the  brain  from  the  effect  pro- 
duced upon  it  as  communicated  to  it.  Question.  By  the  blood  rushing 
to  the  brain  or  withdrawing  from  the  brain  ?  Answer.  It  is  very  difficult 
to  say  what  precisely  does  produce  the  effect.  //  may  be  from  a  change 
j'w  the  electrical  currents  that  we  know  pass  through  the  brain. 

f  The  tender  parts  of  beef,  excluding  the  fatty  and  tendinous  intersec- 
tions, are  scraped  with  a  blunt  knife  in  such  a  way  as  to  retain  the  juice; 
the  mass  is  then  seasoned  with  an  abundance  of  salt  and  a  little  pepper. 
Of  course  it  should  not  be  attempted  to  give  this  palatable  and  nutritious 
dish  to  patients  who  have  the  delusions  that  they  are  compelled  to  eat 
human  flesh,  or  meat  seasoned  with  the  blood  of  their  friends. 


394  INSANITY. 

be  the  chief  food  of  depressed  patients.  Most  vegetables 
and  the  prepared  meats  are  commendable  only  in  patients 
who  at  least  occasionally  take  out-door  exercise.  Very 
good  results  have  been  obtained  by  the  writer  in  epilepsy 
with  and  without  insanity,  by  compelling  a  strictly  vege- 
tarian diet,  as  recommended  by  Browne,  and  this  doubtless 
will  be  found  applicable  in  the  case  of  asylum  patients. 
More  attention  than  is  ordinarily  paid  to  this  branch  of  the 
subject  should  be  devoted  to  the  examination  of  insane 
patients  with  reference  to  the  existence  of  any  disorders 
associated  with  defective  or  perverse  assimilation  ;  the 
proper  treatment  of  lithaemia  and  allied  conditions  will 
often  prove  radically  remedial. 

Melancholiacs,  paretic  dements  and  monomaniacs  labor- 
ing under  delusions  of  persecution  will  frequently  refuse 
food,  fearing  that  it  will  injure  them  {sitophobia),  while 
patients  in  atonic  and  stuporous  states  are  simply  unable  ta 
eat.  Sometimes  maniacal  patients  refuse  to  eat,  but  as  a 
rule  only  for  a  short  time,  and  their  refusal  rarely  becomes 
a  problem  for  the  alienist  to  seriously  consider.  When  a 
melancholiac  refuses  food,  the  rule  is  to  compel  him  to 
take  it  forthwith.  With  maniacs,  monomaniacs  and  paretic 
dements,  temporizing  is  advisable,  because  these  patients 
usually  resume  eating  voluntarily,  and  for  the  additional 
reason  that  their  anorexia  is  often  due  to  a  gastric  disorder' 
which  can  only  be  favorably  affected  by  rest  of  the  organ 
affected.  With  many  of  the  sitophobic  patients  it  sufF.ces  to 
lead  them  to  the  table,  to  put  the  utensils  for  feeding  in 
their  hands,  or  to  feed  them  with  a  spoon.  With  a  large 
number  of  melancholiacs  and  monomaniacs,  with  inspira- 
tional delusions  of  commands  to  abstain  from  eating,  it  is 
necessary  to  resort  to  artificial  feeding.  Temporizing,  ad- 
missible under  other  circumstances,  would  here  be  injurious. 
Particularly  in  melancholia  the  nutritive  disturbance  is  so 
great  that  not  a  day  should  be  lost  in  waiting — frequently  in 
vain — for  a  resumption  of  the  physiological  habits.  The 
most  simple  and  most  readily  extemporized  apparatus  for 
artificial  feeding  consists  in  a  funnel,  to  whose  lower  end  an 
oesophageal  tube  is  attached.  The  tube,  well  oiled,  maybe 
passed  through  a  nostril,  or  through  the  mouth  with  the  aid 
of  an  oral  speculum.  The  latter  should  be  of  strong  make. 
In  passing  the  tube  backward  the  index  finger  of  the  disen- 
gaged hand  should  be  used  as  a  guide.  In  passing  it 
through  the  nostril,  the  possibility  of  its  entering  the  res- 


THE   MEDICINAL  TREATMENT   OF   INSANITY.       395 

piratory  passages  should  be  borne  in  mind.  This  accident 
provokes  coughing,  strangling,  and  cyanosis;  the  two  for- 
mer warnings  may,  however,  be  absent  in  paretic  dements 
with  laryngeal  anaesthesia.  Coughing  and  strangling  may 
ensue  through  irritation  of  the  pharynx  even  when  the  sound 
is  passed  properly,  but  in  this  case  there  are  never  any  in- 
spiratory  noises  produced  in  the  tube;  expiratory  noises  may 
occur  when  the  tube  is  properly  passed  by  escape  of  gas  in 
the  stomach.  The  food  used  in  forced  feeding  should  always 
be  strained  before  being  poured  into  the  funnel,  and  should 
never  be  used  at  a  temperature  above  or  much  below  that 
of  the  body  itself.  Milk,  yolk  of  eggs,  dry  wines,  milk- 
punch,  egg-nog,  beef-juice,  and  hydroleine  are  among  the 
substances  which  can  be  conveniently  administered  in  this 
way.  Medicines  can  also  be  given  mixed  with  the  food, 
and  as  this  is  done  without  the  patient's  knowledge,  is 
often  a  great  advantage  with  a  suspicious  lunatic. 

The  advantage  of  the  funnel  over  the  stomach-pump, 
which  is  frequently  used,  is  that  less  pressure  is  employed, 
that  the  apparatus  does  not  appear  as  formidable  to  a  sus- 
picious patient,  and  that  the  attendants,  if  feeding  should 
be  entrusted  to  them,  will  not  be  tempted  to  omit  the  im- 
portant precaution  of  straining  the  food.  The  stomach 
pump  permits  the  operation  to  be  done  more  quickly,  and 
with  it,  obstruction  caused  by  a  blocking  up  of  the  tube 
may  be  overcome  by  force.  It  should  be  recollected,  how- 
ever, that  nausea  and  vomiting  are  likely  to  ensue  in  case 
the  food  is  introduced  too  rapidly.  Whether  fed  with  the 
funnel  or  the  stomach-pump,  the  patient  should  sit  up,  and 
if  he  is  very  obstructive  a  restraining  chair  will  save  the  pa- 
tient much  needless  muscular  exertion,  the  physician  much 
trouble,  and  diminish  the  chances  of  doing  an  injury.  In 
case  the  oesophageal  tube  is  passed  along  the  floor  of  the 
nasal  cavity,  it  is  apt  to  encounter  a  resistance  and  be  de- 
flected forward  by  a  prominence  which  is  sometimes  very 
marked  on  the  posterior  pharyngeal  wall,  and  which  corre- 
sponds to  the  bodies  of  the  cervical  vertebrae.  Dr.  Tuke 
advises  throwing  the  head  of  the  patient  back  at  the  mo- 
ment when  the  sound  approaches  the  posterior  nares,  the 
tube  having  previously  been  bent  a  little  so  as  to  facilitate 
its  downward  passage;  then  at  the  moment  when  it  is  about 
to  glide  down  into  the  oesophagus,  when  there  is  a  risk  of 
its  passing  into  the  larynx,  he  advises  the  head  to  be  brought 
forwards  and  downwards  so  as  to  send   the   point  against 


396  INSANITY. 

the  posterior  wall  of  the  pharynx.  After  passing  the  upper 
end  of  the  oesophagus,  the  tube  is  usually  swallowed,  as  it 
were,  and  glides  down  without  further  difficulty  into  the 
stomach  through  the  action  of  the  constrictor  muscles. 
At  least  sixteen  inches  of  the  tube  should  be  allowed  to 
pass  down  before  raising  the  funnel  or  using  the  syringe. 

Some  patients  are  artful  in  resisting  forced  feeding,  learn- 
ing to  use  their  abdominal  muscles  in  such  a  way  as  to  com- 
press the  stomach  and  cause  the  food  to  regurgitate.  This 
is  rarely  the  case  in  acute  melancholia,  more  common  in 
monomaniacs  with  certain  delusions,  and  patience  as  well 
as  a  judicious  denial  of  certain  privileges  will  be  necessary 
to  prevent  the  patient  from  carrying  out  his  project  of  self- 
starvation. 

It  is  frequently  found  that  after  having  fed  a  patient  by 
force  several  times,  the  sight  of  the  feeding  paraphernalia 
when  brought  in  for  use  will  induce  him  to  eat  voluntarily. 
It  is  therefore  well  in  every  case  to  make  the  proffer  of 
food  before  resorting  to  extreme  measures,  and  if  it  is 
taken,  it  may  be  advantageous  to  leave  a  little  solid  food  in 
the  room  as  if  by  accident.  In  that  case  it  will  be  found 
that  the  patient  will  eat  it  stealthily,  when  he  supposes  him- 
self unwatched.  It  is  needless  to  add  that  no  food  should 
be  left  in  the  patient's  room,  under  these  circumstances,  to 
eat  which  he  would  require  a  knife,  fork,  or  spoon,  or  any 
vessels  of  porcelain,  glass,  or  tin,  which  he  could  break  and 
open  his  blood-vessels  with;  wooden  platters  will  fulfil  all 
the  requirements  of  the  case. 

Forced  feeding  should  in  stuporous  and  atonic  patients 
be  resorted  to  at  least  three  times  a  day,  and,  if  it  can  be 
done,  once  at  night.  The  nutritive  loss  is  something  enor- 
mous in  these  cases,  it  is  startling  even  in  the  best-fed  pa- 
tients, and  it  is  the  duty  of  the  physician  to  fight  the  foe 
for  every  ounce  of  body-weight,  as  it  were.  With  other 
patients,  feeding  by  force  will  be  necessary,  at  most,  twice 
a  day,  and  rarely  will  they  require  it  for  long  periods.  It 
should  always  be  done  under  the  physician's  immediate  or- 
ders. The  additional  demand  has  been  made,  that  it  should 
always  be  done  in  his  presence,  or  by  him  in  person.  The 
writer  has,  however,  seen  trained  and  other  nurses  perform 
the  operation  with  all  the  skill  and  judgment  which  the 
case  could  possibly  have  required,  and  many  members  of 
our  profession  could  afford  to  learn  the  practical  details  of 
the  operation  from  them.     An  anatomical  demonstration  of 


THE   PSYCHICAL   TREATMENT   OF   THE    INSANE.     39/ 

the  parts  involved  should  be  given  to  every  person  to  whom 
forced  feeding  is  intrusted;  with  this,  and  experience  ac- 
quired undei'  skilled  guidance,  he  may  be  safely  relied  on  to 
carry  out  forced  feeding  himself,  and  without  any  other  aid 
than  that  of  another  and  older  attendant. 

It  is  unnecessary  to  specify  here  the  hygienic  require- 
ments of  the  insane,  which  are  those  of  hospital  patients 
generally.  Patients  who  are  anaemic,  and  particularly 
those  whose  temperature  is  subnormal,  should  be  in  warmer 
apartments  than  ordinary  hospital  patients,  or  those  whose 
disorder  is  of  a  sthenic  type.  In  this  climate  a  temperature 
of  from  65°  to  68°  Fahrenheit,  and  in  some  cases  even  higher, 
is  necessary  in  the  wards  where  demented  and  melancholic 
patients  are  congregated. 


CHAPTER    VII. 


The    Psychical   Treatment    and    Management    of   the 

Insane. 

The  subject  of  the  psychical  treatment  of  insanity  in  its 
widest  sense  comprises  the  prophylactic  treatment  of  the 
insane  predisposition.  This  vast  subject  it  is  impossible  to 
treat  of  in  a  manual,  and  the  writer  contents  himself  with 
expressing  his  opinion  that  in  the  future  certain  educational 
means  will  be  recognized  to  be  as  essential  for  the  diverting 
of  the  mind  inclined  to  perversion  into  healthier  channels, 
as  the  methodical  training  of  certain  muscles  is  essential  in 
preventing  and  remedying  certain  of  the  malformations 
which  come  under  the  cognizance  of  the  orthopoedist. 

The  physician  is  ordinarily  called  upon  to  treat  the 
fully  developed  disease,  and  the  question  of  most  pressing 
importance  which  presents  itself  is  whether  the  patient 
can  be  treated  at  home,  or  whether  it  is  necessary  to 
send  him  to  an  asylum.  In  the  case  of  primary  deterio- 
ration, of  stuporous  insanity,  and  of  the  earlier  phase 
of  syphilitic  dementia,  this  question  may  be  frequently  de- 
cided in  favor  of  home  treatment,  provided  all  the  conven- 
iences for  psychical  and  physical  treatment  are  within  the 
reach  of  the  family.  In  most  other  forms  of  insanity  the 
physician  risks  very  little  by  positively  recommending  asy- 


398  INSANITY. 

lum  treatment.  He  has  three  important  questions  to  con- 
sider: ist.  The  safety  of  society  ;  2d.  The  physical  and 
financial  safety  of  the  family;  3d.  The  interests  of  the  pa- 
tient as  an  individual.  Ordinarily  the  duty  of  the  physician 
is  in  the  first  place  towards  the  individual  patient;  in  the 
case  of  insanity,  however,  there  are  many  other  interests 
than  those  of  science,  and  of  abstract  humanity  to  the  pa- 
tient, involved.  Where  we  have  to  choose  between  the  en- 
dangering of  the  security,  health  and  happiness  of  healthy 
and  useful  members  of  society  on  the  one  hand,  and  the 
compliance  with  sentimental  considerations  advanced  in 
favor  of  decrepit,  dangerous,  or  possibly  useless  ones,  we 
need  not  hesitate  long  in  our  choice — no  longer  than  the 
obstetrician  when  called  upon  to  decide  whether  he  shall 
perform  an  operation  w^hich  would  prove  the  certain  death 
of  a  mother  and  the  possible  salvation  of  her  unborn  child, 
and  another  which  would  result  in  the  death  of  the  child 
but  certain  salvation  of  the  mother,  will  hesitate  to  adopt 
the  latter  alternative.  Fortunately,  the  alienist  is  in  the 
position,  when  complying  with  the  first  two  demands  enu- 
merated, of  acting  at  the  same  time  in  the  best  interests  of 
the  patient  himself. 

The  patients  suffering  from  the  ordinary  psychoses  are 
dangerous  to  society  in  the  following  ways:  ist.  They  may 
commit  homicide,  either  under  the  influence  of  hallucina- 
tory terror  of  imaginary  pursuers,  insane  hatred  of  rivals  in 
their  affection,  or  of  alleged  seducers  of  their  partners  in  life, 
an  insane  desire  for  notoriety  because  of  disappointments 
in  insane  aspirations,  or  under  supposed  inspiration  from 
on  high.  2d.  They  may  commit  arson  or  incendiarism 
either  from  similar  motives  as  those  just  enumerated,  in  the 
thoughtlessness  and  carelessness  of  dementia,  as  the  result 
of  morbid  projects — for  example,  when  a  paretic  dement 
burns  down  his  house  to  build  a  palace  in  its  place — or  in 
obedience  to  the  pyromaniac  morbid  impulse.  3d.  They 
may  make  delusional  charges,  or  false  charges  from  mali- 
cious motives,  against  others,  and  procure  the  punishment 
of  innocent  persons.  4th.  They  may  make  indecent  assaults, 
either  on  account  of  satyriasis,  or  sexual  perversion,  and 
scandalous  exposures  of  their  persons  from  sexual  motives, 
or  in  the  abstraction  of  dementia.  5th.  They  may  destroy 
valuable  property  under  the  influence  of  delusions  or  insane 
antipathy.  6th.  They  may  propagate  their  disorder.  Luna- 
tics are  dangerous  to' their  families  because:  ist.  They  may 


THE   PSYCHICAL   TREATMENT   OF   THE   INSANE.    399 

in  the  abject  gloom  of  melancholia,  or  in  obedience  to  the 
morbid  impulses  of  that  condition,  immolate  whole  fami- 
lies in  a  general  massacre.  2d.  They  may  squander  their 
property  in  insane  speculation,  absurd  purchases,  or  in  ex- 
cesses. 3d.  They  may  develop  mistrust  against  members  of 
the  family,  commit  murder  and  mutilation  on  them,  or  be- 
come the  instruments  of  designing  persons,  and  disinherit 
or  rob  those  who  are  naturally  dependent  on  them.  They 
are  dangerous  to  themselves:  ist,  On  account  of  suicidal 
inclinations;  2d,  through  the  occasional  tendency  to  self- 
mutilation;  3d,  through  the  continuance  in  a  course  of  con- 
duct and  excesses  which  are  calculated  to  intensify  and 
prolong  their  malady.  All  these  considerations  demand 
that  the  insane,  who  are  liable  to  indulge  in  such  acts, 
should  be  beyond  the  range  of  damage  to  themselves  and 
to  others;  and  in  a  large  number  of  cases  the  experienced 
alienist  feels  relieved  of  a  heavy  sense  of  possible  danger 
as  soon  as  the  patient  is  within  the  walls  of  a  properly 
conducted  asylum. 

An  asylum  sojourn  has  in  the  vast  majority  of  cases  a 
good  effect  on  the  insane.  Curable  patients  are  never  in- 
jured in  their  prospects  as  to  curability  in  a  medically  well- 
managed  institution,  and  incurable  patients  should  be  there 
for  practical  reasons,  and  are  usually  better  off  in  than  out 
of  the  asylum. 

The  advantages  of  asylum  treatment  are  the  following: 
I.  Refusal  of  food  and  medicines — the  great  obstacles  to 
the  treatment  of  the  insane  outside  of  asylums — are  best 
dealt  with  by  a  skilful  corps  of  physicians  and  attendants 
always  on  the  spot,  with  the  necessary  appliances  at  their 
disposal.  2.  The  necessary  supervision  of  the  insane  at  all 
hours  can  be  carried  on  with  the  least  expense  and  greatest 
thoroughness  in  the  asylum  ward.  3.  The  excessive  and 
damaging  use  of  narcotics,  calmatives,  and  restraint,  neces- 
sary for  the  purpose  of  preventing  scandal  in  the  neigh- 
borhood, and  noise,  destructiveness,  and  exhaustion  at 
home,  can  be  dispensed  with  in  the  asylum.  4.  The  sojourn 
of  a  patient  in  an  asylum,  the  continual  reminder  which 
the  restraint  of  its  walls  is  to  him  that  he  is  considered  in- 
sane— whether  he  believes  himself  to  be  so  or  not — is  in 
many  cases  a  far  stronger  incentive  to  a  kind  of  reflection 
which  leads  to  the  correction  of  delusions,  than  any  drug. 

With  many  delusional  monomaniacs  psychical  treatment 
is  of  far  greater  value  than  are  food  and  drugs.     If  there 


400  INSANITY. 

is  any  point  of  attack  offered  by  these  disorders  when  in- 
dependent of  perverted  sensations  and  visceral  conditions, 
it  is  the  logical  apparatus.  It  is  true  that  it  is  in  the  over- 
whelming majority  of  cases  impossible  to  reason  such 
patients  out  of  a  delusion,  and  that  where  this  is  possible, 
the  insane  fundament  of  the  insane  thoughts  becomes  the 
soil  for  other  delusions.  But  occasionally  external  influ- 
ences can  be  brought  to  bear  upon  them  in  such  a  way  as  to 
effect  a  rapid  cure.  Leuret  showed  this  in  the  days  when 
the  douche  and  other  forcible  measures  were  more  com- 
monly used  than  now.  He  cured  a  patient,  who  had  the 
delusion  that  he  was  a  king,  by  having  him  douched  when- 
ever he  expressed  that  delusion,  or  responded  to  saluta- 
tions addressed  to  his  imaginary  majesty.  Other  lunatics 
would  find  the  strongest  confirmation  in  such  a  "persecu- 
tion." Undoubtedly  prolonged  restraint  often  leads  to  a 
growing  conviction  that,  after  all,  the  patient's  own  beliefs 
may  be  as  absurd  as  those  of  other  patients  whose  insanity 
he  is  able  to  appreciate,  because  he  discovers  that  they  ad- 
here as  firmly  to  their  beliefs  as  he  has  adhered  to  his. 
More  than  one  instance  of  the  happy  effect  of  a  recognition 
of  the  delusions  entertained  by  others  on  the  patient's  mind 
is  on  record. 

It  cannot  be  our  purpose  here  to  discuss  the  host  of 
questions  touching  the  internal  administration  of  asylums, 
however  intimately  they  may  be  related  to  the  important 
medical  problem  of  the  moral  effect  of  the  institution  on 
the  patient.  It  may  be  expected  of  the  writer  to  express 
his  opinion,  as  he  is  about  to  take  leave  of  his  readers,  with 
regard  to  two  points  which  the  profession,  and  through 
them  the  general  public,  may  require  information  concern- 
ing— ist.  The  advisability  of  discharging  lunatics  on  pro- 
bation during  remissions  of  their  disorder;  2d.  The  use  of 
restraint. 

Remissions  of  insanity,  rarely  amounting  to  absolute 
lucidity,  are  very  common  in  asylums,  particularly  among 
monomaniacs,  the  periodically  insane,  and  paretic  dements. 
There  are  many  cases  recorded  of  periodically  insane  sub- 
jects who  voluntarily  sought  tha  protection  of  the  asylum 
whenever  they  felt  the  morbid  period  approaching;  there 
are  a  limited  number  of  monomaniacs  whose  delusions  are 
entirely  harmless,  and  not  likely  to  change  in  this  respect, 
who  may  support  their  families  and  occupy  a  respectable 
position  in  the  community  when  discharged;  finally,  there 


THE   PSYCHICAL   TREATMENT   OF   THE   INSANE.    4OI 

are  a  few  paretic  dements  who  cannot  be  regarded  as  non 
compos  mentis  in  the  remissions  of  that  disease.  All  these 
classes  are  fit  subjects  for  discharge  on  furlough.  It 
should,  however,  be  determined  in  some  legal  way  that  a 
definite  responsibility  is  assumed  by  the  superintendent 
discharging  such  a  patient,  as  well  as  by  the  relatives  who 
assume  his  charge.  In  Germany,  where  a  furlough  system 
and  such  a  responsibility  exist,  not  a  single  homicide  or 
assault  has  occurred  by  a  lunatic  discharged  under  this 
system,  and  but  a  single  theft,  during  five  years,  the  insane 
out  on  furlough  thus  showing  a  far  better  record  than  the 
sane  population.  It  is  scarcely  necessary  to  add  that  this 
system  can  be  adopted  only  in  communities  in  which  some 
other  factors  than  the  political  or  social  influence  of  men 
who  turn  to  the  asylum  career,  because  they  have  failed  in 
the  general  practice  of  their  profession,  are  potent  in  de- 
termining the  selection  of  medical  officers  of  asylums. 

Much  has  been  written  and  said  about  the  use  and  abuse 
of  mechanical  restraint.  That  this  means  of  controlling 
the  insane  has  been  pushed  to  an  extent  unwarranted  by 
the  emergencies  of  the  case,  there  can  be  no  doubt.  The 
experience  of  the  superintendent  of  the  Auburn  criminal 
lunatic  asylum,  who  is  to-day  able  to  manage  an  unruly 
and  dangerous  class  of  patients  with  a  minimum  of  restraint, 
while  one  of  his  predecessors  not  only  used  a  maximum  of 
restraint  but  also  fired  an  occasional  bullet  among  his 
charges,  is  a  significant  commentary  on  the  correctness  of 
the  position  taken  some  years  ago  by  the  Neurological 
Society  with  reference  to  this  question.  The  concealment 
of  restraint  apparatus,  particularly  of  that  variety  known  as 
the  Utica  crib,  when  foreign  alienists  visit  a  prominent  in- 
stitution in  this  State,  is  a  confession  that  the  apparatus  and 
its  frequent  employment  are,  to  say  the  least,  features  of 
which  no  asylum  can  be  proud.  On  the  other  hand,  it  must 
be  admitted  that  the  agitation  against  restraint  has  over- 
stepped the  bounds  of  legitimate  criticism  and  reform. 
That  there  are  some  subjects  who  require  restraint,  who 
are  better  off  with  than  without  it,  there  can  be  no  doubt. 
The  demonstrative  feat  of  a  novice  superintendent,  who 
burned  all  his  restraint  apparatus  as  soon  as  he  took  charge 
of  his  asylum,  was  followed  by  the  accumulation  of  black 
eyes,  broken  noses,  and  other  minor  surgical  accidents,  as 
well  as  by  several  suicides.  It  is  with  this  question  as  with 
many  others  relating  to  the  internal  economy  of  asylums: 


402  INSANITY. 

reform  cannot  be  accomplished  by  watchwords  and  catch 
phrases,  nor  by  arbitrary  legislation.  The  proper  method 
of  improving  an  asylum  is  to  develop  the  management  and 
supervision  of  asylums  in  a  scientific  direction.  Scientific 
zeal  and  integrity  within  asylums  will  prove  far  better 
guarantees  of  humanity  to  the  insane  than  associations  of 
dilettante  and  newspaper  editorials.  Let  us  hope  that  the 
scientific  spirit  which  was  breathed  into  American  psy- 
chiatry by  Rush  and  Ray,  and  which  has  been  kept  alive 
by  their  immediate  followers,  will  gain  that  preponderance 
which  it  merits  over  an  unworthy  opposition. 


INDEX. 


Abortive  monomania,  311 

Abstraction,  22,  61;  in  paretic  de- 
mentia, 186 

Absurd  beliefs,  21 

Absurdity  of  delusions,  31 

Abulia,  64,  252,  349 

Accusations  of  hysterical  lunatics, 
258 

Active  dementia,  170;  organic 
changes,  123,  178;  phase  of  par- 
etic dementia,  190. 

Acts,  imperative,  36 

Acute  hallucinatory  confusion,  163; 
confusional  insanity,  161 

Acuteness  of  maniacs,  133,  134 

Adhesion  of  dura  to  cranium,  228; 
of  pia  to  cortex,  no,  219 

Adventitia,  changes  of,  106;  gran- 
ular material  in,  102,  107 

Affect,  55 

Affections  in  paretic  dementia,  186 

Age  of  paretic  dements,  216;  influ- 
ence of,  on  hallucinations,  53 

Agitated  dementia,  170;  melan- 
cholia, 145 

Agoraphobia,  36,  65 

Albuminuria,  70,  211 

Albutt,  Clifford,  on  paretic  demen- 
tia, 236 

Alcohol,  use  of,  391 

Alcoholic  delirium,  254;  delusions, 
254;  excesses  in  periodical  insan- 
ity, 270;  hallucinations,  253;  in- 
sanity, 251;  paretic  dementia, 
215;  tremor,  252 

Alternating  consciousness,  59 

Amblyopia,  202 

Amenomania,  288 

Amnesia,  57;  diagnostic  relations 
of, 350;  in  melancholic  frenzy,  143; 


in  transitory  frenzy,  155;  in  par- 
etic dementia,  186 

Amyl  nitrite,  use  of,  387 

Anaemia,  374;  in  melancholia,  144; 
of  brain,  108 

Anaesthesia,  68 

Anatomical  basis  of  mind,  lOi;  pe- 
culiarities in  idiocy,  285;  of  mon- 
omania, 301,  306 

Anatomy,  morbid,  of  insanity,  92 

Aneurismal  changes,  107 

Angry  excitement,  133 

Anomalies,  congenital,  77;  of  cra- 
nium, 86 

Anorexia,  72 

Anthropophagy,  39,  43 

Anxious  hallucinations,  255 

Apathetic  dementia,  168;  phase  of 
paretic  dementia,  189 

Ape-fissure,  286 

Aphasia,  193 

Apoplectiform  attacks,  193,  203, 
206;  albuminuria  after,  211;  re- 
covery from,  216 

Apoplexy,  genuine  in  paretic  de- 
mentia, 206 

Arachnoid,  blood  cysts  of,  109;  cal- 
careous plates  in,  229;  hemor- 
rhage in,  231 

Arcus  senilis,  174 

Argyll-Robertson  pupil,  208 

Arrested    development,    states   of, 

275 
Artefacta,  94 
Artificial  feeding,  394 
Ascending  type  of  paretic  dementia, 

185 
Asylum  treatment,  397 
Asymmetry  of  skull,  87 
Atavism,  278 


404 


INDEX. 


Ataxia,  73;  in  paretic  dementia, 
193,  211 

Athetoid  movements,  206 

Atony  in  melancholia,  145;  in  in- 
itial period  of  mania,  137;  in  stu- 
porous insanity,  158;  inkatatonia, 
152;  of  intestinal  tract,  72 

Atrophy  of  brain,  103;  of  optic 
nerve,  236 

Attitude  of  insane,  74;  of  alcoholic 
subjects,  253;  orgueilleuse,  299; 
frozen,  72 

Aura-like  prodromata,  269 

Austin  on  the  pupil,  207 

Automatic  acts  in  insane,  58,  75 

Axis  cylinders  in  paretic  dementia, 
223 

Baili.arger  on  cortical  changes, 
219;  epileptic  character,  259;  on 
folie a  double  fortne,  1T2.\  on  mono- 
mania, 28S 

Basis  of  mental  co-ordinations,  loi 

Baths,  use  of,  386 

Bedsore,  malignant,  213 

Beliefs,  absurd,  21 

Bell's  typhomania,  249 

Benedict  on  hallucinations,  68 

Billed  on  stramonium,  389 

Bladder  disturbances,  211 

Blanching  of  hair,  78 

Blandford  on  causation,  380;  on 
monomania,  291 

Blind,  insanity  in  the,  49 

Blood  in  insanity,  69 

Bloodcysts,  109,  230 

Blood-stasis.  224 

Blood  supply  in  relation  to  hallucin- 
ations, 47,  53 

Blood-vessels,  changes  of,  106,  224, 
227   232 

Bones,  changes  of,  78 

Bony  plates  in  arachnoid,  228 

Brain  in  insanity,  100;  defects  of, 
go,  285;  cysticerci  in,  112;  hy- 
peraemia  and  anaemia  of,  loS; 
membranes  of,  109;  wasting,  164 

Brierre  de  Boismont  on  extrava- 
gances of  paretic  dements,  187, 
192 

Bromides,  use  of,  385 

Bromism,  339 

Brown  on  brain  wasting,  164 

Brutality  of  paretic  dements,  197 


Bucknill  on  beliefs  of  imbeciles, 
277;  and  Tuke  on  monomania, 
290 

Bulimia,  72,  140;  in  paretic  demen- 
tia, 202 

Calcareous  plates  of  arachnoid, 
229 

Calcification  of  nerve-cells,  104 

Calmeil  on  epileptic  character,  259 

Campagne  on  reasoning  mania,  136 

Cannabalistic  tendencies,  42 

Cannabis  indica,  uses  of,  389 

Cardiac  disorder,  375 

Cataleptic  periods  of  katatonia,  152 

Cathartics,  uses  of,  386 

Causes,  somatic,  of  insanity,  369; 
psychical,  of  insanity,  381;  of 
idiocy,  276;  of  monomania,  301; 
of  transitory  frenzy,  157;  of  stu- 
porous insanity,  159;  of  delirium 
grave,  247 ;  of  primary  deteriora- 
tion, 164 

Cavities  of  the  neuroglia,  106 

Cerebral  tissues,  changes  in,  loi 

Change,  sudden,  of  delusions  in  pa- 
retic dementia,  199 

Character,  epileptic,  260;  in  circu- 
lar insanity,  274;  in  periodical  in- 
sanity, 269;  in  hysterical  insanity, 
257;  change  of,  178;  in  paretic 
dementia,  185;  maniacal,  136 

Chloral,  uses  of,  385 

Chronic  insanity,  373 

Choreomania.  373 

Chronic  alcoholic  insanity,  251;  con- 
fusional  insanity,  170;  delusional 
insanity,  283;  hysterical  insanity, 
256;  mania,  170 

Circular  insanity,  271 

Civilization,  influence  of,  on  paretic 
dementia,  182 

Clarke,  Lockhart,  on  cystic  degener- 
ation, 219 

Classification  of  insanity,  113 

Claustrophobia,  36 

Climacteric  insanity,  122 

Clivus,  anomalies  of  in  pyromania, 
87 

Complicating  insanities,  121,  124, 
129 

Complication  of  one  form  of  insan- 
ity by  another,  128;  of  mono- 
mania, 319,  345 


INDEX. 


405 


Concealed  delusions,  323;  insanity, 

352 
Conceptions,  imperative,  35 
Concussion,  370 
Confession  of    imaginary    crimes, 

141 

Confusion  of  ideas,  162;  acute  hal- 
lucinatory. 163 

Confusional  insanity,  primary,  161; 
secondary,  170;  morbid  changes 
in,  102 

Congenital  anomalies,  77;  mono- 
mania, 30S 

Congestive  attacks  of  paretic  de- 
mentia, 207 

Conium,  uses  of,  3S4 

Connecting  links  of  degenerative 
series,  88 

Connection  between  lesions  and 
symptoms.   113 

Consciousness,  disturbances  of, 
57;  alternating,  59;  double,  59; 
of  impending  loss  of  reason,  61 

Convalescence  of  mania,  139 

Convallaria.  uses  of,  388 

Convulsions,  351 

Convolutions,  atrophy  of,  103;  in 
paretic  dementia,  218 

Coprostasis,  effects  of.  112 

Corpus  callosum  in  imbeciles,  286 

Corrugation  of  brows  in  paretic  de- 
mentia. 210;  in  monomania,  339 

Cortex,  changes  in,  loi;  in  paretic 
dementia,  218;  adhesion  of  pia 
to,  219,  231;  cystic  degeneration 
of,  219;  in  imbecility,  285 

Crampi  in  alcoholism,  252 

Crania  progenia,  87,  282 

Cranial  diploe  in  paretic  dementia, 
22S 

Cranium,  changes  of,  in  insanity,86 

Cretenism.   282 

Crib  of  Utica,  401 

Criminal  acts  of  insane,  398;  of 
paretic  dements.  187 

Cyclothymia,  271 

Cystic  degeneration  of  cortex,  219 

Cysticerci,  112 

Cystitis  in  paretic  dementia,  211 

Dagonet  on  morbid  anatomy,  102 
Dangers  of  insanity.  39S 
Death  in  melancholia,  148;  in  pare- 
tic dementia,  193 


Decubitus,  malignant,  78,  213 
Defects  in  idiotic  brain,  90 
Definition  of  circular  insanity,  271; 
of  delusion,  24,  29;  of  dipsoma- 
nia, 271;  of  hallucination,  43;  of 
illusion,   44;  of  insanity,  17,  19; 
of  katatonia.  149;  of  mania,  131; 
of  melancholia,  141;  of  monoma- 
nia,   301;    of    paretic    dementia, 
241;  of  periodical  insanity,  267; 
of  primary  confusional  insanity, 
161;    of    primary   deterioration, 
163;  of  pubescent  insanity,  175; 
of  senile  dementia,  171;  of  stupo- 
rous insanity,  158 
Degeneration  in  monomania,  293 
Degenerative  changes  in  brain,  102; 

series  of  forms  of  insanity,  88 
Deglutition,  impairment  of,  211 
Deliberation  of  the  insane,  64 
Deli  re  dcs  actes,  270 
Delirium,  341;  acutum.  247;  of  epi- 
leptic   insanity,  264;   grave,    80, 
247;    of   mania,  133;    of   melan- 
cholic  frenzy,  143;  of  monoma- 
nia,   296;    of    paretic   dementia, 
192,  203;  tremens,  251;   hysteri- 
cal, 217 
Delusion,  definition  of,  24 
Delusional  insanity,  288;  monoma- 
nia, 312 
Delusions    of    alcoholic    insanity 
254;     of     confusional     insanity 
162;  diagnostic  bearing  of,  340, 
348;  in  delirium  grave,  248;  de 
tection    of,  327;    depressive,   28 
141;   erotic,   27,  300;    expansive 
27,  298;  genuine,    25;    of  grand 
eur,    32,    248;    hypochondriacal 
26;  of  mania,  138;  of  marital  infi- 
delity, 33;  mechanism  of,  28;  of 
melancholia,  141;  modifying   in- 
fluence of  external  circumstances 
on,    34;  of  visceral    impressions 
on,  33;  of  paretic  dementia,  195, 
199;  persecutory,    26;    religious, 
27,  304;  rudimentary,    36;  of  se- 
nile dementia,  173;  spurious,  25; 
systematized,     25,    288;     unsys- 
tematized, 25,  31, 
Dementia   agitated,  170;  brain  in, 
108;  epileptic.  259;  frequency  of, 
168;  nerve  cells  in,  104;  neurog- 
lia  in,    106;  paretic.    178;   para- 


4o6 


INDEX. 


lytic,  179;  passive,  168;  senile, 
171;  syphililic,  243;  terminal, 
166;  trophic  changes  in,  171; 
varieties  of,  119,  120 

Depressed  states,  differential  diag- 
nosis of,  330 

Depressive  delusions,  141;  period 
of  mania,  137 

Descending  type  of  paretic  demen- 
tia, 214 

Destruction  of  nerve-cells,  105,  223 

Detection  of  simulation.  364 

Deterioration,  primary,  163;  secon- 
dary, 166;  of  nerve  cell  proto- 
plasm, 222 

Development,    states   of,  arrested, 

275 

Diagnosis  of  insanity,  320,  330;  of 
circular  insanity,  273 

Diarrhoea,  72 

Diet  of  insane,  393 

Digitalis,  uses  of,  388 

Differential  diagnosis  of  the  vari- 
ous forms,  330 

Diminutives,  use  of,  in  katatonia, 
152 

Diploe  in  paretic  dementia,  228 

Diplopia,  240 

Dipsomania,  37,  271 

Discoloration  of  cortex,  219 

Disseminated  sclerosis,  223 

Diurnal  change  of  symptoms  in 
melancholia,  149 

Double  consciousness,  59,  163 

Down,  on  ethnic  types  in  idiocy, 
279 

Dreams  causing  delusions,  33;  in 
primary  deterioration,  164 

Drunkenness,  influence  of,  on  pro- 
geny, 83 

Dura  mater,  inflammation  of,  109, 
228 

Duration  of  mania,  138;  of  melan- 
cholia, 147;  of  paretic  dementia, 
216 

Dysuria  spastica,  72 

Ecstatic  states,  258 

Effluvium  in  mania,  72 

Ego,  60 

Egotism  in   senile   dementia,  172; 

in  monomania,  309 
Electricity,  uses  of,  393 
Electro-muscular  reactions,  67 


Emminghaus  on  exophthalmic  goi- 
tre, 376 

Emotional  disturbance,  56;  insan- 
ity, 551  disturbance  in  mania,  132; 
in  melancholia,  140;  tremor,  209; 
diagnostic  importance  of,  349 

Emotions  in  imbeciles,  281 

Endyma,  changes  of,  220 

Engelhorn  on  transitory  frenzy, 
156 

Ependyma  layer  in  imbecility,  285 

Epilepsy,  relation  of,  to  periodical 
insanity,    91;  in    imbeciles,   282; 

Epileptic  insanity,  258:  dementia, 
259;  morbid  anatomy  of,  99,  102, 
107;  chronic,  261;  intervallary, 
261;  handwriting  in,  266 

Epileptiform  attacks  in  paretic  de- 
mentia, 193,  203,  205;  pathology 
of,  227 

Episodical  attacks  of  paretic  de- 
mentia, 203;  pathology  of,  237; 
delirium  in  monomania,  296 

Epithelial  granulations  of  pia,  109 

Equivalent,  psychical  epileptic,  259 

Erotic   delusions,  27;  monomania, 

317 

Erotomania,  27,  300 

Erlenmeyer  on  syphilitic  hypo- 
chondriasis, 243 

Errors  of  pathologists,  93;  of  Uti- 
ca  school,  95;  of  sane  as  differ- 
ing from  delusions,  28 

Esquirol  on  epileptic  dementia,  259; 
on  monomania,  287;  on  morbid 
anatomy,  96 

Etat  criliW,  107 

Ethnic  types  in  idiots,  278 

Etiology  of  insanity,  369,  381;  of 
paretic  dementia,  240 

Etiological  forms,  115,  370-379 

Examination  of  the  insane,  320 

Excesses  of  paretic  dements,  190 

Exhaustion,  maniacal,  139 

Exhileration  of  paretic  dements, 
192 

Expenditures,  extravagant,  192 

Explosion  of  paretic  dementia,  190 

Exposure,  indecent,  188 

Expression  of  the  insane,  74,  322 

Extravagant  projects,  ig8 

Facial  appearance  of  alcoholic  sub- 
jects, 253 


INDEX. 


407 


Factors  determining  delusions,  31 

Faithful  memory  of  insane,  58 

Falret  on  epileptic  insanity,  260;  in 
folie  circulaire,  271 

Fatty  changes  of  nerve-cells,  105 

Feeble-mindedness,  275 

Females,  paretic  dementia  in,  196, 
217;  periodical  insanity  in,  376 

Fever,  secondary,  of  syphilis;  in- 
sanity in,  244 

Fibrillary  change  of  neuroglia,  105, 
106;  tremor,  337 

Flemming  on  recovery  from  pa- 
retic dementia,  216 

Flight  of  ideas  in  mania,  132 

Fluxionary  states  in  insanity,  107 

Folie  a  double  forme,  272;  a  deux, 
367;  circulaire,  271;  communi- 
que'e,  367;  du  doiite,  308,  311; 
raissonante,  65 

Fournier  on  pseudoparalyses,  246 

Foville  on  cranial  deformity,  87;  on 
transitory  frenzy,  155 

Free  nuclear  bodies,  proliferation 
of,  225 

Frenzy,  melancholic,  142;  transi- 
tory, 154;  melancholic,  143 

Frequency  of  mania,  13S;  of  mel- 
ancholia, 148;  of  senile  demen- 
tia, 175;  of  pubescent  insanity, 
177;  of  paretic  dementia,  180 

Fright,  precordial,  in  melancholia, 

143 

Frozen  attitude,  72 

Furloughs  for  insane,  401 

Furor,  135:  maniacorum,  135;  of 
paretic  dementia,  192,  204;  transi- 
tory, 55 

Fiirstner  on  cortical  lesions  in  pa- 
retic dementia,  243 

Fury,  pathological,  55, 

Gait  in  paretic  dementia,  210 
Galloping  paretic  dementia,  203 
Ganglionic  bodies  of  cortex,  changes 
in,  104;  in  paretic  dementia,  221 
Gangrene,  pulmonary,  80,  213 
Gauster  on  recovery  in  paretic  de- 
mentia, 216 
Generosity  of  paretic  dements,  194 
Goitre  exophthalmic,  376 
Gouty  insanity,  374 
Grand  mat  intellectuel,  260 
Grandeur,  delusions  of,  336 


Granular  matter  in  adventitia,  102, 

107;  wasting,  222 
Granulations,  epithelial,  of  pia,l09; 

of  ventricular  endyma,  220 
Gray,  L.  C.,  on  temperature,  71 
Griesinger   on    Griibelsucht,   36,  58, 

311;  on  primary  and  secondary 

forms,  289 
Ground-glass  appearance,  221 
Grossemuahnsimi,  295 
Griibelsucht,  36,  65,  311 
Gruyere  cheese  appearance,  219 
Giintz  on  senile  dementia,  174 
Grave  delirium,  247 
Gyri  of  idiot's  brain,  278 

H.'EMATOMA  of  ear,  79;  of  dura, 
230 

Haematuria  in  paretic  dementia,  211 

Hallucinations,  43;  definition  of, 
43;  visual,  50;  auditory,  51 ;  gus- 
tatory and  olfactory,  53;  unilat- 
eral, 52;  in  paretic  dementia, 
200;  in  katatonia,  152;  in  mel- 
ancholia, 142;  in  mania,  134;  in 
monomania,  313,  316,  318;  in  al- 
coholic insanity,  253;  differential 
diagnostic  relations  of,  349;  in 
the  sane,  21 

Hallucinatory  mania,  134;  confu- 
sion, 163 

Hammond,  on  mysophobia,  36;  on 
extravagances  in  paretic  demen- 
tia, 192,  203;  on  Kalmuck  idiocy, 
278 

Handwriting  of  insane,  76;  in  pa- 
retic dementia,  210;  in  monoma- 
nia, 76;  in  epileptic  insanity,  266 

Headache  in  katatonia,  152;  in  pa- 
retic dementia,  338 

Head  injuries,  370 

Head  sensations  in  melancholia, 
144;  in  confusional  insanity,  163 

Heart  disease  in  insanity,  375 

Hebephrenia,  176 

Hecker  on  hebephrenia,  176 

Haemorrhage  of  brain  in  paretic 
dementia,  206 

Haemorrhagic  pachymeningitis  ,229 

Hereditary  transmission,  275;  mo- 
dus of,  83;  transformations  in 
course  of,  91 

Herpetic  eruptions,  78 

His,  perivascular  space  of,  106,  227 


4o8 


INDEX. 


Homicidal  impulse,  37;  in  melan- 
cholia. 146;  monomania,  36 

Howard  on  temperature  of  insane, 
69,  71 

Hughes  on  simulation,  358 

Huguenin  on  durhaematoma,  229 

Hyaline  thrombi,  527 

Hyoscyamia,  uses  of,  389 

Hypersemia  of  optic  disc,  67,  236, 
of  brain,  108;  of  cortex,  239;  in 
delirium  grave,  250 

Hyperaethesia,  68;  in  alcoholic  in- 
sanity, 212 

Hyperalgesia,  68 

Hyperbulia,  64,  349 

Hypochondriacal  delusions  in  mel- 
ancholia, 141;  in  monomania, 
316 

Hypochondriasis,  syphilitic,  243 

Hypocrisy  in  hebephrenia,  176 

Hypomania,  136;  like  condition  in 
paretic  dementia,  203 

Hysterical  insanity,  256 

Identity,  changed  sense  of,  60; 
in  confusional  insanity,  162;  in 
mania,  134 

Idiocy,  275;  brain  defects  in,  90; 
gyri,  278;  varieties  of,  276;  ata- 
visms in,  278;  ethnic  types  of, 
278;  instincts  in,  279 

Illusions,  43;  definition  of,  44;  of 
sight,  50;  of  hearing,  51;  of 
smell  and  taste,  53;  of  identity, 
50;  in  paretic  dementia,  200;  de- 
pendence of  on  tinnitus  aurium, 

53 
Imbecility,    275,    280;    moral,  281; 

partial,   281;  anatomical    defects 

in,  90,  285 
Imitative  tendencies  of  idiots,  280 
Imperative   conceptions    and  acts, 

35.  36,  349;  movements,  75 
Impression,  maternal,  influence  of 

on  progeny,  84 
Impulse,   homicidal,    37;    morbid, 

36,  270 

Inconsistency  of  unsystematized 
delusions,  33;  in  hebephrenia, 
176;  in  paretic  dementia,  195 

Increased  frequency  of  paretic  de- 
mentia, 183 

Indecent  exposure,  187 

Inebriety,  252 


Inequality  of  pupils,  207,  336 

Inflammatory  process  in  paretic  de- 
mentia, 218,  238 

Influence  of  insanity  on  disease, 
80 

Inhibition,  logical,  29;  in  mania, 
132;  in  melancholia,  141 

Initial  stage  of  mania,  137;  of  mel- 
ancholia, 147;  of  katatonia,  149; 
of  paretic  dementia  184 

Injuries  of  head,  369 

Insane  attitude,  74;  expression,  74, 
321;  manner,  74,  321 

Insanity,  definition  of,  17,  19;  cir- 
cular, 271;  delusional,  288;  dis- 
simulated, 353;  intellectual,  293; 
morbid  anatomy  of,  92;  moral, 
2S1;  primary,  289;  secondary, 
289;  simulated,  352;  somatic 
signs  of,  81;  trophic  disturbanc- 
es of,  77 

Insanity  of  pubescence,  175;  pro- 
pensities of,    176;  frequency  of, 

177 

Insolation,  369,  371 

Insomnia  in  primary  deterioration, 
164;  treatment  of,  385 

Instincts  in  idiots,  279 

Intellectual  labor  as  a  cause  of  in- 
sanity, 382. 

Intellectual  insanity,  293 

Intensification  of  neurotic  vices  in 
transmission,  85 

Intervals  of  paretic  dementia,  193 

Intervallary  epileptic  insanity,  261 

Intestinal  tract  in  insanity,  71 

Interstitial  encephalitis,  221 

Ireland  on  varieties  of  idiocy,  276 

Iron,  uses  of,  392 

Irritability  in  paretic  dementia, 
188,  189 

Isthmus  affections  in  paretic  de- 
mentia, 241 

Jacobi  of   Germany,  somatic  the- 
ory of,  71 
Jessen  on  delirium  grave,  249 
Johnson,  case  of,  75 
Jolly  on  hallucinations,  68 

Kahlbaum  on  katatonia.  149 
Kalmuck  idiocy,  278,  358 
Katatonia,   149;    hallucinations  in, 
152;    prognosis    and    frequency 


INDEX. 


409 


of,  153;  morbid  anatomy  of,  98, 
102,  230 

Kiernan  on  othaematoma,  79;  on 
katatonia,  149;  on  transitory 
frenzy,  155,  156,  157;  on  athetoid 
movements  in  paretic  dementia, 
206;  on  trophic  changes,  212, 
232;  on  simulation,  358;  on  use 
of  ergot,  387 

Kinking  of  blood-vessels,  107,  226 

Kirchhoff  on  original  monomania, 
307 

Kirn  on  pupillary  spasm,  75 

Kleptomania,   37,  270 

Koster  on  periodical  insanity,  268 

Krafft-Ebing  on  stigmata,  89;  on 
degenerative  forms,  116;  on 
morbid  anatomy,  97;  on  classi- 
fication, 117;  on  hysterical  insan- 
ity, 257 

LacuNv*;  of  memory  in  paretic  de- 
mentia, 192;  in  syphilitic  demen- 
tia, 244 

Lamination  of  cortex,  obliteration 
of,  lOI 

Lasegue  and  Garel,  on  crania  of 
epileptics,  87 

Le  Grand  du  Saulle  on  stigmata, 
89 ;  on  folie  du  doute,  311 

Legal  aims  of  a  definition  of  insan- 
ity, 19 

Legal  insanity,  23 

Leptomeningitis,  231 

Lesbian  love,  42 

Lettervvriting  tendency,  210 

Leucin  precipitates,  manufactured 
at  Utica,  95 

Leuret,  illusion  of,  53 

Lymphatic  flow,  retardation  of, 
102,  106,  108 

Lypemania,  287 

Locomotion  disturbances,  350 

Locomotor  ataxia  in  paretic  de- 
mentia, 210;  its  analysis,  240 

Logical  inhibition,  29 

Lubimoff  on  paretic  dementia,  223 

Lucid  intervals  in  paretic  dementia, 
193;  in  mania,  139 

Magnetic   illusions,  54;   in   pare- 
tic dementia,   200 
Malarial  insanity,  374 


Maldevelopment  after  organic  af- 
fections, 82 

Malignant  decubitus,  213 

Mania,  defiiition  of,  131;  delusions 
in,  134;  depressive  stage  of,  137; 
duration  of,  138;  errabunda,  181; 
exhaustion  in,  139;  chronic,  288; 
frequency  of,  138;  in  puerpero, 
133.  377;  identity,  change  of 
sense  of,  134;  hallucinations  in, 
134;  hallucinatory,  134;  gravis, 
247;  morbid  anatomy  of,  97;  mel- 
ancholic, 137;  periodical,  269; 
prognosis  of,  138;  recurrent,  140; 
transitory,  55,  154;  typical,  131 

Maniacal  excitement,  120;  in  kata- 
tonia, 152;  fury,  135;  furor  in 
paretic  dementia,  203;  morbid 
anatomy  of,  227 

Manie  grave,  123;  raissonante, 
65;  systematisee,  288 

Manner,  insane,  74 

Mannerisms  of  insane  writings,  77 

Marasmus  of  nerve-tissue,  172 

Marce  on  monomania,  288 

Marital  infidelity,  delusions  of,  33, 
254 

Marks  of  insane  resembling  bruises, 
80 

Masturbation,  378;  in  hebephrenia, 
176,  177 

Masturbatory  insanity,  54,  379 

Maternal  impressions,  84;  prepon- 
derance of  influence  of,  82 

Maudsley  on  classification,  114 

Mechanism  of  hallucinations,  44 

Medicinal  treatment  of  insanity, 
384;  means  for  detecting  simula- 
tion, 368 

Medico- Psychological  Association, 
classification  proposed  by  com- 
mittee of,  114 

Megalomania,  200,  295 

Melancholia  agitata,  144;  anaemia 
in,  114;  attonita,  145;  cum  stu- 
pore,  145;  delusions  in,  31,  141; 
definition,  140;  duration,  147; 
ex  lactatio,  377;  from  masturba- 
tion, 379;  frenzy  in,  142;  fre- 
quency of,  147;  hallucinations 
in,  142;  head-symptoms  in,  144; 
homicide  in,  146;  in  puerpero, 
378;  mild,  146;  maniacal,  142; 
morbid  anatomy  of,  98;  progno- 


4IO 


INDEX. 


sis  of,  148,  149;  periodical,  271; 
precordial  fright  in,  143;  pulse 
in,  143;  sine  delirio,  69,  146,  148; 
suicide  in,  146;  self-mutilation 
in,  142;  weight  in,  144;  without 
delusions,   146 

Memory,  disturbances  of,  57;  in 
melancholia  and  mania,  140;  in 
imbecility,  281;  in  dementia, 
165;  in  paretic  dementia,  192 

Mendacity  in  paretic  dementia, 
198;  215 

Mendel  on  mania,  97;  on  hypoma- 
nia,  136;  on  hallucinatory  mania, 
134;  on  paretic  dementia,  231;  on 
haematoma,  230 

Meningitis,  370;  from  over-study, 
248. 

Meningo-myelitis,  232 

Menstrual  insanity,  267,  376 

Metallic  poisons,  374 

Meynert,  on  hallucinations,  46;  on 
melancholia,  98;  on  brain-weight 
in  insanity,  109;  on  paretic  de- 
mentia, 223 

Mickle  on  paretic  dementia,  197, 
199,  201 

Microgyria,  286 

Micromania,  200 

Mild  melancholia,  146 

Miliary  aneurisms,  107;  sclerosis, 95 

Milky  opacity  of  leptomeninges, 
109;  231 

Mind,  anatomical  basis  of,  loi 

Miserly  inclinations  in  paretic  de- 
mentia 190;  in  senile  dementia, 
172 

Monomania,  abortive,  311;  abuse  of 
term,  287;  brain-defects  in,  90; 
congenital,  308;  definition  of,  300; 
delusional,  312;  diagnosis  of,  335; 
erotic,  317;  handwriting  in,  76; 
homicidal,  36;  history  of,  286; 
masturbatory  380;  morbid  an- 
atomy of,  99,  no;  persecutory, 
299,314;  prognosis  of,  31S;  queru- 
lous, 315;  reasoning,  309;  re- 
ligious, 300;  relation  of,  to  im- 
becility, 88,281;  secondary,  170; 
sine  delirio,  309 

Alonomanie  gaie,  288;  triste,  288; 
vaniteuse,  295 

Moos  on  hallucinations  of  hearing, 
53 


Moral  insanity,  56,  281;  imbecility, 
56,  281;  perversion,  56;  deteri- 
oration in  paretic  dementia, 
190 

Morbid  anatomy  of  insanity,  92; 
of  paretic  dementia,  218;  of  de- 
lirium grave,  250;  impulses,  36, 
270;  propensities. 35,  38 

Morel  on  stigmata  of  heredity, 89; 
on  classification,  115;  on  mon- 
omania, 288 

Moria,  341;  post-epileptic,  269 

Motor  disturbances,  73;  in  katat- 
onia,  150;  in  paretic  dementia, 
191,  242,  209;  in  imbeciles,  282 

Motor  excitement  in  mania,  135; 
as  a  factor  in  differential  diagno- 
sis, 335 

Alouvetnents  en  viandge,  206 

Movements,  imperative,  75;  rhyth- 
mical, 75 

Multiple  sclerosis,  214 

Muscular  coat  of  arteries  in  paretic 
dementia,  225 

Musky  odor  of  idiots,  73 

Mutism,  255,  337 

Mysophobia,  36,  65 

NASSEon  pupil  in  paretic  dementia, 
208 

Necrobiosis  of  ganglionic  bodies, 
221 

Necrophilism,  43 

Negative  pathology  of  mania,  97 

Nerve-cells,  atrophy  of,  103,  104, 
221 ;  destruction  of,  103;  pigmen- 
tation of,  102;  in  acute  delirium, 
104,  250;  in  mania  and  melan- 
cholia, 104 

Neumann  on  paretic  dementia  in 
females,  217 

Neuroglia,  changes  in,  105;  nuclei 
of,  105;  in  paretic  dementia,  223 

Neuroses,  dependence  of  insanity 
on,  124 

Neurosis,  traumatic,  371;  hysteri- 
cal, 256;  epileptic,  258;  alcoholic, 
251 

New  formation  of  vascular  chan- 
nels, 225 

Nitrite  of  amyl,  uses  of,  387 

Nuclear  bodies  of  neuroglia,  105 
in  imbeciles,  286;  proliferation 
of,  in  adventitia,  106 


INDEX. 


411 


Nutritive  disturbances  in  insanity, 

104 
Nymphomania,  27,  39,  380 

Objective  surroundings,  recogni- 
tion of,  by  the  insane,  62 

Oblongata,  changes  of,  in  paretic 
dementia,  223 

Obscenity  of  maniacs,  132 

Occipital  headache  in  katatonia, 
152;  lobe  in  paretic  dementia,  202, 
243;  in  imbeciles,  286 

Oddities  of  behavior  in  paretic  de- 
dementia,  215;  of  speech  in  in- 
sane, 351 

Oophorectomy,  376 

Opium,  uses  of ,  388;  insanity  from, 
254,  255,  271 

Optic  papilla  in  paretic  dementia, 

235 

Organic  changes  in  alcoholic  in- 
sanity, 128,  251;  in  senile  de- 
mentia, 128 

Originiire  Verriicktheit,  301 

Osteophytes  of  sella  turcica,  87 

Othaematomata,  78 

Outbreak  of  mania,  137;  of  deliri- 
um grave,  248;  of  periodical 
mania,  269 

Over-study,  effects  of,  248 

Pacchionian  bodies,  109 
Pachymeningitis,    229;    hemorrha- 
gica, 229 
Papilla  optic,  in  paretic  dementia, 

235 

Paraesthesia,  68 

Paralucid  intervals  of  paretic  de- 
mentia, 193 

Parental  influence,  82 

Paresis,  73 

Paretic  dementia,  178;  abstraction 
in,  186;  affections  changed  in, 
186;  age  of  subjects  of,  216; 
alcoholic  form,  215;  amblyopia 
in,  202;  apathy  in,  189;  aphasia 
in,  193;  apoplectiform  attacks  in, 
193,  203,  206;  ataxia  in,  191,  193; 
bladder  disturbance  in,  211;  bru- 
tality in,  197;  bulimia,  202;  causes 
of,  240;  change  in  character  of 
delusions  of,  199 ;  character, 
peculiarities  in,  185;  complicat- 
ing other  forms  of  insanity,  338; 


course  of,  184;  decubitus  in,  213; 
deglutition  impaired  in,  211;  de- 
lusions of,  192,  195,  196,  197; 
diagnosis  of,  338;  duration  of, 
216;  epileptiform  attacks  in,  193, 
203,  205;  episodial  attacks  of,  203; 
exhilaration  in,  192,  194;  explo- 
sion of,  190;  extravagant  expendi- 
tures in,  192;  female  cases  of, 
196,217;  frequency  of,  180;  furor 
in,  204;  gait  in,  210;  galloping 
form  of,  203;  generosity  in,  194; 
hallucinations  in,  200;  handwrit- 
ing in,  209,  210;  hemorrhage  in, 
206;  hypochondriacal,  phases  of, 
200;  initial  period  of,  184;  irrita- 
bility in,  189;  isthmus  changes 
in,  241;  letter-writing  tendency 
in,  210;  lucid  intervals  of,  193; 
maniacal  attacks  in,  203;  men- 
dacity in,  198;  miserliness  in,  190; 
morbid  anatomy  of,  99,  100,  2x8; 
moral  deterioration  in,  190; 
motor  disturbance  of,  209;  neu- 
roglia in,  223;  oblongata,  changes 
in,  223;  optic  papilla  in,  235; 
perivascular  spaces  in,  107;  pia 
in,  231;  pons,  changes  in,  21S, 
223;  physical  signs  of,  190;  prog- 
nosis of,  215;  prodromal  period 
of,  184;  projects  in,  192,  198; 
ptosis  in,  209;  pulse  in,  212; 
pyonephritis  in,  211;  relation  of 
lesions  to  symptoms  of,  236,  243; 
relation  of  physical  and  mental 
signs,  178,  180;  remissions  of, 
193,  214;  sclerosis  in,  214;  sens- 
ory disturbances  in,  201,  211; 
septic  complications  of,  213; 
speech  disordered  in,  209;  spider- 
shaped  cells  in,  223;  spinal  cord 
in,  231;  spinal  symptoms  of,  240; 
suffocation  in,  210;  stages  of, 
1S4;  temperature  in,  212;  tremor 
in,  209;  trophic  disturbances  of, 
193,  212;  varieties  of,  214;  vaso- 
motor disturbances  in,  212;  white 
substance,  changes  of,  in,  223 

Partial  insanity,  90,  287;  punish- 
ability, 52 

Parturient  state,  378 

Passive  dementia,  170 

Pathological  fury,  55:  results  of 
insane  excitement,  no, rii 


412 


INDEX. 


Pathos  in  katatonia,  150 

Pellagrous  insanity,  124,  125 

Pelman  on  pupil  in  paretic  demen- 
tia, 208 

Pemphigus  in  delirium  grave,  250 

Penuriousness  in  senile  dementia, 
172 

Periganglionic  spaces,  106;  in  par- 
etic dementia,  220 

Periodical  insanity,  lesions  of,  107; 
relation  of,  to  epilepsy,  91 ;  defi- 
nition of,  267;  mania,  269;  melan- 
cholia, 271;  morbid  impulses  270; 
prognosis  of,  274 

Peritonitis,  influence  of,  on  de- 
lusions, 33,  34 

Perivascular  spaces,  106,  220 

Persecutory  delusions,  26;  mono- 
mania, 318 

Perversion,  moral,  56;  sexual,  39 

Petit  vial  intellectuel,  260 

Pfleger  on  brain-weight,  109 

Phosphates,  loss  of,  in  insanity,  69 

Phosphorus,  uses  of,  69,  392 

Photopsia  in  relation  to  hallucina- 
tions, 255 

Phrenitis,  247 

Phthisical  insanity,  375 

Physical  signs  of  insanity,  65;  of 
senile  dementia,  174;  of  paretic 
dementia,  207;  of  alcoholic  in- 
sanity, 

Pia,  changes  of,  in  insanity,  109, 
no;  in  paretic  dementia,  231 

Pigmentation  of  nerve-cells,  102, 
104,  222 

Plagiarism  committed  by  the  in- 
sane, 27 

Planning  of  insane  acts,  64 

Plates,  bony,  in  membranes  of 
brain, 22S 

Ponicare  and  Bonnet,  theory  of,  as 
to  paretic  dementia,  235 

Pons,  changes  in  paretic  dementia, 

Popular  idea  of  insanity,  359 

Porencephaly,  384 

Post-epileptic  insanity,  260;  stupor, 
260;  moria,  261 

Post-febrile  insanity,  373 

Post-mortem  changes  in  the  brain, 

95 
Precordial  fright,  143 
Predisposition     to    insanity,     382; 

signs  of,  81 


Pre-epileptic  insanity,  261 

Pregnancy,  morbid  propensities  in, 
38;  insanity  in, 

Preponderance  of  maternal  in- 
fluence in  heredity,  82 

Primary  confusional  insanity,  i6i; 
prognosis  of,  163 

Primary  dementia,  160,  177,  379; 
insanity,  122,  289;  mental  deteri- 
oration, 163 

Primordial-Delirieti,  292 

Principles  of  classification,  118,  119 

Prisoners,  insanity  in,  49 

Prognosis  in  alcoholic  insanity, 
256;  in  hebephrenia,  177;  in  hys- 
terical insanity,  258;  influence  of 
haematoma  on,  79;  in  katatonia, 
153;  in  mania,  138;  in  melan- 
cholia, 148 ;  in  masturbatory  cases, 
379;  in  monomania,  318;  in  peri- 
odical insanity,  279;  in  paretic 
dementia,  215;  in  primary  confu- 
sional insanity,  163;  in  senile  de- 
mentia, 174;  in  stuporous  insan- 
ity, 160. 

Progressive  Paralyse,  179 

Progressive  Paresis,  180 

Projects  of  the  insane,  27 

Propensities,  morbid,  35,  38 

Pseudo-emotional  states  in  paretic 
dementia,  209 

Pseudo-monomania,  288 

Pseiidoparalysie  g^n^rale,  246 

Psychical  degenerative  states,  321; 
causes  of  insanity,  381;  treat- 
ment, 397 

Psychoneuroses,  121 

Ptosis  in  paretic  dementia,  209;  in 
neurotic  subjects,  339 

Puerperal  state,  insanity  of,  377 

Pulse  in  melancholia,  143;  in  pare- 
tic dementia,  212 

Pulsus  tardus,  70 

Punishability  of  the  insane,  52 

Pupil  in  insanity,  75;  in  paretic  de- 
mentia; Argyll-Robertson,  208; 
diagnostic  importance  of,  336 

Pure  insanity,  forms  of,  121 

Pyonephritis  in  paretic  dementia, 
211 

Pyromania,  37;  cranial  deformities 
in,  87 

Qiierulanten-  Wahnsinv,   315 


INDEX. 


413 


Querulous  monomania,  315 
Quiet  type  of  paretic  dementia,  2 14, 
217 

Race,  question  of,  in  relation  to 
paretic  dementia,  181 

Radiant  heat  as  a  cause  of  insan- 
ity. 371 

Raptus  melancholicus,  143 

Rarefication  of  neuroglia,  223 

Reactions,  electro-muscular,  67 

Reasoning  of  maniacs,  133;  mono- 
mania, 309 

Recurrent  mania,  140 

Reflexes  in  stuporous  insanity,  159 

Refusal  of  food,  394 

Reich  on  transitory  frenzy,  157 

Reinhard  on  septic  complications 
of  paretic  dementia,  213 

Relation  of  skull-shape  to  insanity, 
86,  87 

Religious  delusions,  27 ;  mono- 
mania, 304 

Remissions,  400;  of  paretic  demen- 
tia, 214 

Restraint,  401 

Retardation  of  lymph-outflow  from 
cortex,  102,  106,  108 

Retina  in  insanity,  66 

Retinal  after-image,  analogy  of,  to 
memory,  44 

Reversion  of  idiots  to  apes,  horses, 
sheep  and  other  animals,  claim 
of.  276,  277 

Rheumatic  insanity,  374;  causation 
of  paretic  dementia,  215 

Rhythmical  movements  in  insane, 
75;  in  delirium  grave,  249;  in 
katatonia,  151 

Richarz  on  parental  influence,  82 

Ripping  on  insanity  in  puerpero, 
377;  on  syphilitic  psychoses,  245 

Rush  on  moral  imbecility,  56;  on 
nomenclature,  288 

Saliva,  dribbling  of,  159 
Samt  on  post  epileptic  insanity,  260 
Sander  on  origindre  Ve7'riicktheit,2,o?> 
Sankey  on   vascular  kinking,   226; 

on  monomania,  291 
Satyriasis,  39,  173 
Schopenhaur,  case  of,  92 
Schiile  on  delirium  grave,  247;  on 


frequency  of  paretic  dementia  in 
females;  on  hyoscyamime,  389; 
on  morbid  anatomy  of  mono- 
mania, 99;  on  recovery  of  paretic 
dementia,  216 

Sclerosis  of  cortex,  219;  of  oblon- 
gata, 223;  of  cord,  232;  cerebro- 
spinal, 216,  223,  240;  miliary, 
95;  of  optic  papilla,  236 

Secondary  fever  of  syphilis,  insan- 
ity with,  243;  deterioration,  166; 
insanity,  122,  289;  insanity  with 
confusion  of  ideas,  170;  partial 
insanity,  170 

Self-consciousness,  60 

Self-mutilation  in  melancholia,  145 

Sella  turcica  in  pyromania,  87 

Senile  dementia,  171;  anatomical 
changes  in,  106;  definition  of, 
171;  delusions  in,  173;  hyperaes- 
thesia  in,  174;  frequency  of,  175; 
memory  in,  172,  173;  insanity, 
171 

Sensibility,  disturbances  of,  68;  in 
paretic  dementia,  211 

Sentiments  distinct  from  emotions, 
55 

Sex,  relation  of,  to  mania,  13S;  to 
melancholia,  148;  to  paretic  de- 
mentia, 217;  to  periodical  insan- 
ity, 274 

Sexual  ideas  in  paretic  dementia, 
196;  mutilation,  delusion  of,  254; 
perversion,  39,  308;  sensations 
in  hysterical  insanity  and  mono- 
mania, 258,  312 

Shepard's  definition  of  insanity, 221 

Shrinkage  of  pyramidal  bodies  of 
cortex,  221 

Simon  on  paretic  dementia,  191, 
197,  202 

Simulation,  352;  by  hebephreniacs, 
176;  by  hysterical  patients,  257; 
by  masturbatory  lunatics,  379; 
by  the  insane,  357 

Sitophobia,  394 

Skae's  classification,  115 

Skin  in  insanity,  72,  78,  363 

Skull,  condition  of,  in  paretic  de- 
mentia, 228;  deformity  of,  86; 
asymmetry  of,  87,  305 

Snell  on  syphilitic  paretic  demen- 
tia, 244;  on   Vcryiicktheit,  244 

Somatic  etiology  of   insanity,  369. 


414 


INDEX. 


signs  of  insanity,  8i;  disturb- 
ances in  alcoholism.  253 

Special  senses,  illusions  and  hallu- 
cinations of,  50 

Speech  in  insanity,  76;  disturb- 
ances, 350;  in  paretic  dementia, 
191,  209;  in  idiots,  280 

Spider-shaped  cells  in  paretic  de- 
mentia, 223 

Spinal  cord  in  paretic  dementia, 
231-235;  lymph-spaces  of,  220; 
type  of  paretic  dementia.  185 

Sphygmograph,  revelations  of,  70, 
213 

Stages  of  paretic  dementia,  1S4 

Stasis,   thrombic,  229,  239 

States  of  arrested  development,  275; 
epileptic  mental,  259 

Stearns  on  electrical  basis  of  mind, 

393 

Stigmata  of  heredity,  86,  89,  279, 
350 

Stomach  pump,  use  of,  395 

Stramonium,  use  of.  389 

Strychnia,  use  of,  389 

Stuporous  insanity,  120;  definition, 
1 58;  prognosis  of,  160 

Suffocation  in  paretic  dementia, 211 

Suicidal  impulse,  37 

Suicide  in  melancholia,  141,  146 

Sunuitnrische  Erinneriiiig,  59 

Sutherland  on  the  blood  in  insan- 
ity, 69 

Symptomalogy  of  the  various  forms 
of  insanity,  131-329 

Syphilitic  dementia,  244;  hypo- 
chondriasis, 243 

Systematized  delusions,  25,  295, 
314 

T.^^DiUM  vitae  in  paretic  dementia. 

179 

Taint,  constitutional,  signs  of,  81 

Temperature  in  insanity,  71;  in 
paretic  dementia,  212;  in  deie- 
rium  grave.  249 

Terminal  deterioration,  166  ;  de- 
mentia, 169 

Tetanic  condition  of  muscles  in  in- 
sanity, 74 

Theatrical  behavior  in  katatonia, 
150.  151 

Thefts  committed  by  paretic  de- 
ments, 187 


Theomania,  300 

Thrombic  stasis,  227 

Thunderstruck  melancholia,  145 

Thyroid  gland  in  cretiiiism,  284 

Touch-sense,  disturbances  of,  in 
paretic  dementia,  201;  transfor- 
mation of  psychosis  in  hereditary 
transmission,  gi.  275;  of  delu- 
sions in  monomania,  316 

Transition  of  mania  to  melancholia 
in  circular  insanity,  274 

Transitory  frenzy,  154,  377;  furor, 
55;  mania,  55,  154 

Transmission  of  hereditary  vices, 
modus  of,  83,  84,  275;  intensifica- 
tion of  neurotic,  vice  in,  85,  86 

Traumatic  insanity,  370 

Tremor,  351;  ataxic,  209;  emotion- 
al, 209;  paretic,  209;  alcoholic, 
252 

Treviranus  on  brain  in  sleep,  47 

Tristimania,  288 

Trophic  disturbances  in  insanity, 
77.  350;  in  paretic  dementia,  193, 
212;  in  delirium  grave,  249 

Tuke,  D.  Hack,  on  classification, 
115;  on  artificial  feeding,  395 

Turnbull  on  paretic  dementia  in 
the  young,  216 

Typhomania,  247 

Ullrich,  case  of,  40 
Undue  influence  in  senile  demen- 
tia, 173 
Unilateral  hallucinations,  52 
Unsystematized  delusions,   25,  31, 

195.  197 

Urine  in  insanity,  69;  in  paretic  de- 
mentia, 212 

Utica  crib,  401;  spurious  pathol- 
ogy of  school  at,  95,  96 

Van  der  Kolk  on  sympathetic  in- 
sanity, 71 

Varieties  of  idiocy,  276;  of  paretic 
dementia,  214;  of  mania,  136;  of 
melancholia,  144;  of  monomania, 
295,  314;  of  periodical  insanity, 
269 

Vascular  walls,  changes  of,  106; 
strain,  effects  of,  107,  no 

Vaso  motor  condition  in  paretic  de- 
mentia, 212,  237 

Venesection,  indications  for,  386 


INDEX. 


415 


Ventricles  in  paretic  dementia,  220; 

granulations  of,  220 
Verbigeration  in  katatonia,  151 
Verriicktheit  primdre,    289;    origu 

ndre,  301 
Vesicular  degeneration^of  cord,  233 
Violence   as   a   cause   of  othaema- 

toma,  78 
Virchow  on  durhsematoma,  229 
Visceral  sensations  as  basis  of  illu- 
sions, 54;  lesions  in   insane,  iii, 

112 
Visions,   341;  in  paretic   dementia, 

236;  monomania 
Vogt  on  idiots,  275 
Voisin    on     classification,    116,    on 

anosmia  in  paretic  dementia,  igo; 

on  pulse  in  paretic  dementia,  212 
Vulgarity  of  paretic  dements,  190 

Wahnsinn,  289 

Wasting  of   brain,  164;   in  paretic 

dementia,  218 
Weakness,   mental,  in  its  differen- 
tial diagnostic  relations,  350 


Weight  of  brain,  in  insanity,  108; 
of  body  in  circular  insanity,  273; 
in  melancholia,   144 

Westphal  on  imperative  concep- 
tions, 40;  on  confusional  insan- 
ity, 163 

White  substance  of  brain,  changes 
in,  103,  223 

Will,  disturbances  of,  64;  in  alco- 
holic insanity,  252;  in  paretic  de- 
mentia, iSS 

Winslow  on  double  consciousness, 

59 
Wolff  on  pulsus  tardus,  70 
Word-stoppage  in  paretic  dementia, 

207 
Wundt  on  normal  temperament,  189 

Yandell  on  epidemic  insanity,  373 
Young,  paretic  demetia  in  the,  216 

Zacchias  on  recognition  of  insan- 
ity by  the  insane,  62;  on  detec- 
tion of  simulation,  364 


v 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

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This  book  is  DUE  on  the  last  date  stamped  below. 


■^^yy/iiS  137a 


BioME&*PR-2A^8 


JUNO  7  ;'p 

'BIOM»1V|'/ft^S'l'l98b 


Biomed  Ar  K        i 
Uwm»^  APR       1 


19(11 


BiMm  A%R  1 

FEB    4 


981 


41981 


Form  L9-40m-5,'67(H2161s8)4939 


